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1 


GYNECOLOGY 


By 

WILLIAM  P.  GRAVES,  A.  B.,  M.  D.,  F.  A.  C.  S. 

Professor   of    Gynecology   at   Harvard    Medical    School;     Surgeon-in-Chief 

to    the    Free    Hospital   for   Women,    Brookhne;      Consulting  Physician  to 

the  Boston  Lying-in  Hospital 


With  368  Half-Tone  and  Pen  Drawings  by 

The  Author 

And  123  Microscopic  Drawings  by 

Margaret  Concree  and  Ruth  Huestis 

With  100  of  the  Illustrations  in  Colors 


SECOND  EDITION,  THOROUGHLY  REVISED 


PHILADELPHIA    AND    LONDON 


W.  B.  SAUNDERS    COMPANY 


1918 


Copyright,  1916,  by  W.  B.  Saunders  Company.     Reprinted  February,  1917-     Revised 
•^    reprinted,  and  recopyrighted  July,  1918 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED    iN    AMERICA 

PRESS    OF 

W.    B.     SAUNDERS    COMPANY 

PHILADELPHIA 


TO  THE   MEMORY   OF 

Dr.  MtlUam  M.  Baker 

TEACHER   AND   FRIEND 

THIS   BOOK   IS 

GRATEFULLY  AND  AFFECTIONATELY 

DEDICATED 


PREFACE  TO  THE  SECOND  EDITION 


An  attempt  has  been  made  in  this  edition  to  bring  the  book  as  completely 
as  possible  up  to  date.  Special  attention  has  therefore  been  paid  to  those 
subjects  in  which  the  science  of  gynecology  has  made  the  greatest  recent 
advances.  Thus  the  section  on  the  Relationship  of  Gynecology  to  the  Internal 
Secretions  has  been  almost  entirely  rewritten  and  considerably  amplified. 
Much  new  material  has  been  added  to  the  discussion  of  such  subjects  as 
ovarian  organotherapy',  ovarian  transplantation,  the  radium  treatment  of 
cancer,  radium  therapy  in  non-mahgnant  gynecologic  diseases,  etc.  A  new 
section  has  been  introduced  dealing  with  the  relationship  of  gynecology  to  the 
sex  impulse,  based  chiefl}'  on  the  now  generally  accepted  theories  of  Freud 
regarding  infant  sexuality.  In  Part  III,  which  deals  exclusively  with  oper- 
ative gynecologj^  a  number  of  new  operations  have  been  described  and  illus- 
trated, most  of  which  have  not  appeared  before  in  text-books.  Manj^  draw- 
ings have  been  added,  most  of  them  illustrating  new  material.  Some  of  them 
have  been  substituted  for  such  illustrations  in  the  first  edition  as  seemed 
inadequate. 

W.  P.  Graves. 

Boston,  Mass., 
July,  1918. 

7 


PREFACE 


This  work  is  designed  both  as  a  text-book  and  general  reference  book  of 
Gynecology.  In  order  to  meet  these  two  requirements  a  special  classification 
has  been  adopted  dividing  the  subject  matter  into  three  distinct  parts: 

Part  I  deals  with  the  physiology  of  the  pelvic  organs  and  with  the  relation- 
ship of  gynecology  to  the  general  organism.  The  latter  subject  is  a  compara- 
tively new  departure,  and  is  presented  in  conformity  with  the  latest  methods 
of  medical  teaching  which  strive  to  impress  on  the  student's  mind  the  importance 
of  the  correlation  of  all  branches  of  medicine  and  surgery.  It  is  hoped  that  this 
part  of  the  work  will  prove  of  value  both  to  the  advanced  special  student  and 
to  the  general  practitioner  who  includes  gynecologic  patients  in  his  chentele. 

Part  II  is  designed  primarily  for  the  undergraduate  student  who  is  taking  his 
initial  course  in  gynecology.  It  includes  a  description  of  those  diseases  which 
are  essentially  gynecologic,  and  is  thus  isolated  in  a  somewhat  compact  form  in 
order  that  the  student  may  not  be  confronted  by  a  too  formidable  array  of  facts 
in  his  collateral  reading  and  in  his  preparation  for  his  final  examination  in  the 
subject.  In  order  to  accomplish  this  purpose  certain  encumbering  details  have 
been  subordinated.  Thus,  in  the  description  of  each  disease,  the  underlying 
pathologic  processes  are  enumerated.  Microscopic  detail,  however,  can  better 
be  learned  from  pictures  than  from  tedious  descriptions.  For  that  reason  draw- 
ings from  microscopic  sections  illustrating  the  respective  diseases  are  presented 
under  each  subject  with  full  descriptive  legends  appended  to  them.  In  like 
manner  the  surgical  principles  involved  in  the  treatment  of  the  various  dis- 
eases are  recounted,  but  the  technic  of  the  operations  and  the  pictures  illustrating 
their  performance,  matters  of  secondary  interest  to  the  student  of  the  theory 
of  gynecology,  are  reserved  for  a  separate  section. 

Part  III  is  devoted  exclusively  to  the  technic  of  gynecologic  surgery  and  is 
written  for  the  assistance  of  the  advanced  student  and  practitioner.  Surgical 
devices  for  the  cure  of  gynecologic  diseases  are  innumerable,  and  it  is  impossible 
to  include  them  all  in  a  book  of  this  scope.  Only  those  operations  which  from 
the  personal  experience  or  judgment  of  the  author  seem  best  suited  for  the 
special  requirements  are  presented.  Many  excellent  procedures  have,  there- 
fore, been  unavoidably  omitted. 

In  preparing  a  work  of  this  kind  material  must  be  gathered  not  only  from  the 
author's  personal  experience,  but  to  a  still  greater  extent  from  the  work  of 
others.  Out  of  a  great  number  of  authorities  consulted  there  have  been  several 
to  which  I  have  had  such  frequent  recourse,  both  for  new  material  and  for  cor- 

9 


10  PREFACE 

roboration  of  personal  observations,  that  I  must  make  a  general  acknowledg- 
ment of  indebtedness  to  them.  In  writing  the  sections  on  the  relationship  of 
g;ymecology  to  the  general  organism  I  have  received  the  greatest  assistance  from 
the  monumental  work  entitled  "Die  Erkrankungen  des  Weiblichen  Genitales 
in  Beziehung  ziu-  imieren  INIedizin/'  published  by  Prof.  Frankl-Hochwart  as  a 
supplement  to  Nothnagel's  "Pathologie  und  Therapie."  In  writing  Part  II 
the  authorities  to  which  I  owe  most  are  the  great  "Handbuch"  of  Veit,  the 
"Handbuch"  of  Opitz  and  IMenge,  the  "Lehrbuch"  of  Ktistner,  and  the  various 
works  of  Dr.  Howard  A.  Kelly  and  his  associates. 

In  making  the  half-tone  drawings  I  owe  much  to  the  instruction  of  ]\Ir.  IMax 
Brodel,  who  manj^  years  ago  showed  me  the  technic  which  he  has  developed 
and  which  has  been  universally  imitated,  but  never  equalled,  in  the  field  of  medi- 
cal illustration.  To  ]\Iiss  H.  J.  Ewin,  Superintendent  of  the  Brookline  Free 
Hospital  for  Women,  I  am  indebted  for  the  accumulation  and  tabulation  of  a 
vast  number  of  statistics  gathered  from  hospital  records  and  patients'  letters. 
On  the  basis  of  these  statistics  I  have  been  able  to  draw  many  valuable  conclu- 
sions. To  my  associate,  Dr.  F.  A.  Pemberton,  belongs  the  credit  of  selecting 
the  pathologic  sections  and  of  supervising  the  microscopic  drawings,  most  of 
which  have  been  executed  bj^  Miss  Margaret  Concree. 

Several  of  the  illustrations  have  been  pubHshed  previous^  in  an  article  by 
the  author  in  the  American  Practice  of  Surgery. 

William  P.  Graves. 

Boston,  Mass. 


CONTENTS 


PIRT    I— PHYSIOLOGY    AXD    RELATIONSHIP    OF    GYNECOLOGY 
TO    THE    GENERAL    ORGANIS^I 

PAGE 

Physiology  of  the  Uterits  axd  Ovaries 1" 

The  Uterus 1" 

Physiologic  Anatomy  of  the  Ovary 31 

Relationship  of  Gynecology  to  the  Gen-er.al  Okg-^nism 44 

Relationship  of  G}-necolog>-  to  the  Organs  of  Internal  Secretion 44 

Ovary 46 

H^■poph3'sis ■ ^3 

Th^vToid ' " 

ParathjToids °3 

Suprarenal  System - ^"^ 

Pineal  Gland  (Epiphysis) 90 

Thj-mus 91 

Uterus 91 

Placenta 9^ 

Relationship  of  Cxj-necology  to  the  Mammary  Glands 93 

Relationship  of  GjTiecolog\-  to  the  Skin 94 

Relationship  of  Gjmecology-  to  the  Organs  of  Sense 98 

Relationship  of  G^^lecolog^-  to  the  Digestive  Tract 100 

Relationship  of  G^-necolog}-  to  the  Organs  of  Respiration 103 

.  Relationship  of  Gj-necology  to  the  Blood 105 

Serodiagnosis HO 

Relationship  of  GjTiecologj'  to  the  Organs  of  Circulation 112 

Heart 113 

Blood-vessels H^ 

Relationship  of  GjTiecologj"  to  the  Nervous  System 120 

Relationship  of  G^mecology  to  the  Sex  Impulse 129 

Infantile  Sexuahty 130 

Sexual  Deviations 134 

Relationship  of  Gjmecolog}-  to  the  Xeighboring  Organs 141 

Relationship  of  Gj-necolog\-  to  the  Gall-bladder 14' 

Relationship  of  G>-necolog>-  to  the  Peritoneum  and  Omentum 150 

Relationship  of  GvTiecology  to  the  Bones  and  Joints 156 

Relationship  of  Gj-necologj-  to  Acute  Infectious  Diseases 157 

Enteroptosis "'^ 

Movable  Kidnev 


Intestinal  Bands 


172 


PART   II— GYNECOLOGIC   DISEASES 


Special  Infl-anoiatory  Processes 1 ' 


Gonorrhea . 


i: 


Gonorrhea  in  Children 1  ^^ 

Gonorrhea  in  the  Adult 1^1 

11 


12  CONTENTS 

Special  Inflammatory  Processes — Gonorrhea — Gonorrhea  in  the  Adult —  page 

Urethritis Igl- 

Inflammation  of  Skene's  Glands 183 

Inflammation  of  Barthohn's  Glands 184 

Endocervicitis 189 

Endometritis 192 

Salpingitis 192 

Chronic  Pelvic  Inflammation  as  a  Result  of  Gonorrheal  Salpingitis 209 

Serum  and  Vaccines  in  Gonorrhea 214 

Genital  Tuberculosis 215 

Tubes 216 

Uterus 219 

Ovaries 220 

Cervix 220 

Vagina . 220 

Vulva 220 

Peritoneum 221 

General  Inflammatory  Processes 224 

Inflammations  of  the  Vulva 224 

Soft  Chancre 224 

Skin  Lesions 225 

Esthiomene 229 

Elephantiasis 230 

Kraurosis 232 

Pruritus 234 

Vaginitis  (or  Colpitis) 236 

Cervicitis  and  Endocervicitis 241 

Endometritis 242 

Infectious  Endometritis 244 

Chronic  Interstitial  Endometritis , 247 

Gland  Hypertrophy 249 

Metritis 251 

Inflammations  of  the  Ovary ; 252 

Infectious  Oophoritis 252 

Interstitial  Oophoritis 253 

Parametritis  and  Pelvic  CeUuhtis 255 

Inflammations  of  the  Pelvic  Cellular  Tissue 256 

Parametrial  Hematoma 260 

Urethritis .261 

Cystitis 262 

Tuberculosis  of  the  Bladder 271 

Syphilis  of  the  Bladder 272 

Cystitis  Vetularum 272 

Pyelitis 273 

Inflammations  of  the  Colon  and  Rectum 277 

Diverticiilitis 277 

Ischiorectal  Abscess 280 

Fistula  in  Ano • 281 

Fissure  in  Ano 282 

Inflammatory  Stricture  of  the  Rectimi 283 

New  Growths 286 

Tumors  of  the  Vulva 286 

Fibroma  and  Fibromyoma 286 

Lipoma 287 


CONTENTS  13 

New  Growths — Tumors  of  the  Vulva —  p^eg 

Carcinoma 287 

Sarcoma 292 

Varicocele 293 

Urethral  Caruncle 293 

Urethral  Prolapse 294 

Tumors  of  the  Chtoris 295 

Tumors  of  the  Vagina 296 

Sarcoma 296 

Carcinoma 297 

Cysts 299 

Tumors  of  the  Uterus 307 

Myoma 307 

Adenomyoma 327 

Sarcoma 328 

Cervical  Polyps 332 

Cancer  of  the  Cervix 334 

Cancer  of  the  Body  of  the  Uterus 362 

Chorio-epithelioma  Malignum " 370 

Tumors  of  the  Ovaries ;  .   381 

FolHcle  Cysts 381 

Corpus  Luteum  Cysts 385 

Parenchymatous  Tumors 387 

Cystadenoma 387 

Carcinoma 398 

Dermoid  Cysts 401 

Teratoma 404 

Stromatogenous  Tumors 407 

Sarcoma 410 

Symptoms 412 

Diagnosis 415 

Treatment 416 

Prognosis 417 

Parovarian  Cysts 418 

Tumors  of  the  Tubes 420 

Carcinoma 420 

Other  Tumors  of  the  Tube 421 

Tumors  of  the  Round  Ligament 422 

Tumors  of  the  Pelvic  Connective  Tissue 423 

Tumors  of  the  Bladder 426 

Papilloma 426 

Carcinoma 427 

Vesical  Calculus 428 

Tumors  of  the  Rectum 429 

Cancer • 429 

Adenoma 431 

Prolapse 431 

Hemorrhoids 432 

Defects  of  Development 436 

Congenital  Defects  of  the  Uterus 441 

Vagina 444 

Ovaries  and  Tubes 445 

Urethra  and  Bladder 445 

Atresia  of  the  Anus 449 

Pseudohermaphroditism 451 


14  CONTENTS 


PAGE 


Malpositions  of  the  Uterus 453 

Retroversion  and  Retroflexion 458 

Retroversion  due  to  Relaxation 459 

Retroversion  due  to  Adhesions 468 

Retroversion  due  to  Displacement  by  Tumors 470 

Prolapse  and  Procidentia 470 

Prolapse 470 

Procidentia 475 

Anteflexion 480 

Inversion 482 

Injuries  Due  to  Childbirth 485 

Lacerations  of  Cervix 485 

Cystocele 487 

Lacerated  Perineum 490 

Vesical  Fistula .  498 

Abdominal  Hernia 500 

Umbilical  Hernia 502 

Postoperative  Hernia 503 

Special  Gynecologic  Diseases. 506 

Ectopic  Pregnancy 506 

Dysmenorrhea 515 

Essential  Dysmenorrhea 515 

Membranous  Dysmenorrhea 522 

Amenorrhea  of  Youth ; 523 

Menorrhagia  of  Youth 524 

Radium  in  the  Treatment  of  Non-malignant  Gynecologic  Diseases 525 

Vaginismus 533 

Gynatresia 535 

Genital  Atrophy 540 

Uterine  Insufficiency 547 

Infantalism  and  Sterility 549 

General  Symptomatology  in  Gynecology 568 

Symptoms  due  to  Abnormal  Secretions 568 

Abnormahties  of  Menstruation 571 

Amenorrhea 571 

Menorrhagia 573 

Metrorrhagia 575 

Pain. 576 

PART   III— OPERATIVE   GYNECOLOGY 

Operations  on  the  Vulva ■. 582 

Vulvectomy 582 

Special  Operation  for  Cancer  of  Vulva 584 

Operations  on  Bartholin's  Glands 588 

Operations  on  the  Cervix 591 

Dilatation  of  the  Cervix 591 

Curetage 592 

Tracheloplasty 593 

Amputation  of  the  Cervix 599 

Schroder's  Operation 604 

Operations  on  the  Vagina 608 

Anterior  Colpoplasty  (Author's  Method) 608 

Operation  for  Functional  Incontinence  of  Urine 614 


CONTENTS  15 

Operations  on  the  Vagina — •  page 

Anterior  Colpoplasty  (Clark's  Technic) 617 

Combined  Amputation  of  Cervix  and  Anterior  Colpoplasty (SO 

Emmet's  Perineoplasty  (Author's  Technic) 625 

Clark's  Perineoplasty 633 

Studdiford's  Perineoplasty 638 

ObHteration  of  Douglas'  Pouch  for  Rectocele  (Author's  Method) 643 

Enlarging  a  Tight  Perineum 646 

Operations  for  Complete  Laceration  of  the  Perineum 647 

Operations  for  Vesical  Fistulse 653 

Operations  for  Atresia  of  the  Vagina 665 

Operations  for  Absence  of  Vagina 667 

Schubert's 670 

Baldwin's , 670 

Vaginal  Celiotomy 675 

Anterior  and  Posterior  Colpotomy 675 

Operations  for  Uterine  Malposition 678 

Operations  for  Retroversion 678 

Olshausen's  Operation  for  Suspension  of  the  Uterus  (Author's  Technic) 678 

Various  Forms  of  the  Gilliam  Operation 680 

Simpson's  Operation 681 

Mayo's  Modification  of  Gilliam's  Operation  (Internal  Alexander) 683 

Kelly's  Modification  of  Gilliam's  Operation 685 

Baldy's  Operation  (also  called  the  Baldy-Webster  Operation) 685 

Alexander's  Operation -688 

Operations  for  Anteflexion 691 

Pessaries  for  Anteflexion  of  the  Cervix 691 

Operations  on  the  Cervix  for  Anteflexion 693 

Abdominal  Operation  for  Anteflexion  (Author's  Method) 695 

Operations  for  Prolapse  and  Procidentia 696 

Procidentia 696 

.  Watkins'  Interposition  Operation 699 

GofTe's  Operation 706 

Mayo's  Operation 709 

Conservative  Operation  for  Inversion  of  the  Uterus 710 

Spinelli's  Operation  for  Inversion  of  the  Uterus 711 

Hysterectomy  Operations 713 

Supravaginal  Hysterectomy 713 

Complete  Hysterectomy 724 

Vaginal  Hysterectomy , 728 

Wertheim's  Extended  Operation  for  Cancer  of  the  Uterus 731 

Extended  Vaginal  Hysterectomy  for  Cancer  of  the  Cervix 744 

Myomectomy  Operations 750 

Abdominal  Myomectomy 750 

Vaginal  Myomectomy 756 

Operations  on  the  Tubes 757 

Salpingo-oophorectomy 757 

Salpingectomy 758 

Salpingostomy  (Stomatoplastic) 760 

Operation  for  Tubal  Sterilization 762 

Operations  on  the  Ovaries 764 

Resection  of  the  Ovary 764 

Transplantation  of  Ovarian  Tissue 765 


16  CONTENTS 


PAGE 


Operations  on  the  Abdominal  Wall 768 

Bardenheuer's  Incision 768 

The  Pfannenstiel  Incision 769 

Operation  for  Diastasis  of  the  Rectus  Muscles : , 771 

Operation  for  Umbihcal  Hernia  (Author's  Method) 775 

Mayo's  Operation  for  Umbihcal  Hernia 781 

Operation  for  Postoperative  Hernia 782 

Transplantation  of  Fascia  for  Postoi>erative  Hernia 782 

Operation  for  Femoral  Hernia 787 

The  Percy  Cautery  for  Cancer  of  Cervix 790 

Technic  in  the  Application  of  Radium 792 

Operations  on  the  Kidney 796 

Minor  Operations , 796 

Suspension  of  the  Ividney  (Kelly's  Technic) 800 

Incision  for  Major  Operations  on  the  Kidney 803 

Nephrectomy 803 

Operations  on  the  Ureters 810 

Uretero-ureterostomy 810 

Ureterocystanastomosis 812 

Extirpation  of  the  Kidney 813 

Ligation  of  the  Proximal  End  of  the  Ureter ^ 813 

Formation  of  Ureteral  Fistula 814 

Operations  on  the  Bladder : 815 

Suprapubic  Cystotomy 815 

Vaginal  Cystotoiny 815 

Operations  on  the  Rectum , 817 

Operations  for  Prolapse 817 

Operations  for  Hemorrhoids 819 

Operations  for  Fistula  in  Ano 824 

Elting's  Operation  for  Fistula  in  Ano 827 

Operations  for  Varicose  Veins  of  the  Leg 828 

Technic 831 

Examination  of  the  Patient 831 

Pelvic  Examination  in  a  Private  House 834 

Abdominal  Operations 835 

Technical  Detail  in  Conduct  of  Abdominal  Pelvic  Operations 836 

Postoperative  Treatment  of  Abdominal  Cases 840 

Technic  of  Plastic  Surgery 842 

Technical  Details 843 

After-care 845 


Index 849 


GYNECOLOGY 


PART    I 

PHYSIOLOGY  AND  RELATIONSHIP  OF  GYNECOLOGY  TO 
THE   GENERAL  ORGANISM 


PHYSIOLOGY    OF    THE    UTERUS    AND    OVARIES 
THE   UTERUS 

During  the  first  decade  of  life  the  female  genitalia  play  a  very  unimportant 
physiologic  role.  In  the  last  months  of  intra-uterine  life  there  is  a  somewhat 
rapid  development  of  the  uterus,  and  at  birth  is  often  seen  a  discharge  which 
appears  hke  true  menstrual  blood.  The  uterus  then  for  several  months  under- 
goes a  process  of  regression,  from  which  period  there  is  a  very  slow  growth 
until  the  time  of  puberty. 

The  hypertrophic  changes  in  the  uterus  just  before  and  after  birth  are 
at  present  supposed  to  be  due  to  the  action  of  hormones  from  the  placenta, 
which  influence  the  development  of  the  maternal  uterus  and  that  of  the  child, 
both  of  which  undergo  involution  when  the  stimulus  of  the  placenta  is  removed 
(Halban). 

At  birth  the  uterus  is  high  in  the  pelvis  and  pressed  backward  by  the  intes- 
tines which  lie  in  the  utero vesical  space.  At  this  time  it  is  pointing  upward 
and  its  axis  is  practically  straight.  During  the  first  ten  years  of  life  it  sinks 
gradually  deeper  in  the  pelvis,  and  acquires  the  angulation  between  body 
and  cervix  known  as  anteflexion.  There  is  also  a  tendency  to  sag  backward 
toward  the  sacrum  into  the  position  of  retrocession.  The  persistence  of  this 
position  after  maturity  constitutes  the  typical  condition  of  local  infantiUsm. 

The  growth  of  the  inner  genitaha  during  the  first  ten  years  is  comparatively 
slight,  but  toward  the  age  of  puberty  there  is  a  very  marked  and  rapid  develop- 
ment. The  uterus  does  not  usually  attain  its  full  growth  in  the  virgin  until 
several  years  after  puberty. 

Child-bearing  increases  the  size  and  weight  of  the  uterus,  so  that  it  measures 
on  an  average  1  cm.  more  in  each  dimension  than  does  the  virgin  uterus  and 
weighs  about  20  gm.  more.  The  length  of  the  virgin  uterus  is  7  to  8  cm.,  and 
its  weight  from  40  to  50  gm.     During  lactation  the  uterus  undergoes  a  tempo- 

2  17 


18  GYNECOLOGY 

rary  atrophy  due  to  a  shrinking,  but  not  a  loss  of  the  muscle-fibers,  and  normally 
regains  its  proper  size  after  lactation  ceases.  At  the  menopause  the  uterus 
becomes  permanently  atrophied  as  a  result  of  a  diminution  both  in  size  and 
amount  of  muscle  tissue. 

The  ovaries  of  the  child  during  the  first  ten  years  also  show  an  insignificant 
growth.  The  infantile  ovary  is  narrow  and  slender.  Toward  puberty  there 
is  a  rapid  development,  and  the  organ  assumes  a  rounder,  more  oval  contour. 
The  dimensions  of  the  mature  ovary  are  3  to  5  cm.  long,  2  to  3  cm.  wide,  and 
1  to  If  cm.  thick. 

In  the  fetus  the  tube  is  twisted  into  tight  convolutions,  which  straighten 
out  somewhat  toward  the  end  of  intra-uterine  fife,  especially  near  the  isthmus. 
As  the  child  grows  older  the  tube  gradually  becomes  straighter,  so  that  at 
puberty  there  are  only  moderate  convolutions.  After  child-bearing  the  tube 
becomes  nearly  straight.  The  twisting  of  the  tube  sometimes  persists  after 
maturity,  and  is  regarded  as  one  of  the  stigmata  of  infantihsm.  It  is  thought 
to  be  one  of  the  causes  of  sterility  and  of  tubal  pregnancy. 

At  puberty  the  secondary  sexual  characteristics  become  more  pronounced 
and  differentiated  from  those  of  the  male.  Most  important  of  these  are  the 
development  of  the  breasts,  relative  width  of  the  hips,  slenderness  of  the  waist, 
length  of  the  hair  of  the  head,  small  bony  structure,  general  undulating  contour 
of  the  body,  and  absence  of  body  hair,  except  in  the  axillse  and  on  the  pubes. 

The  breasts  at  the  time  of  birth,  both  in  boys  and  girls,  are  enlarged,  and, 
like  the  female  uterus,  undergo  retrogression  in  the  first  fev\^  weeks.  It  is 
thought  that  this  enlargement  of  the  breasts  at  birth  is  due  to  the  influence 
of  the  placenta,  to  which  is  also  ascribed  the  growth  of  the  maternal  breasts 
during  pregnancy.  The  rapid  mammary  development  at  puberty  and  the 
temporary  enlargement  during  menstruation  is  probably  referable  to  the  in- 
fluence of  the  ovarian  inner  secretion  (Halban-Schrdder) . 

Woman  reaches  her  highest  period  of  development  and  her  greatest  fertifity 
about  the  middle  of  the  third  decade  of  life. 

Physiology  of  Menstruation. — Menstruation  is  probably  established  at  the 
time  of  the  first  complete  ripening  of  an  ovum.  The  first  appearance  of  blood 
usually  takes  place  at  about  the  fourteenth  year,  though  in  some  it  begins  as 
early  as  eleven  and  in  others  as  late  as  sixteen.  These  may  be  regarded  as 
the  normal  Hmits.  Precocious  menstruation  in  infants  is  usually  due  to  some 
disturbance  in  the  glands  of  internal  secretion,  while  late  menstruation  (i.  e., 
after  sixteen)  is  commonly  the  result  of  some  ovarian  deficiency,  either  primary 
in  the  ovaries  themselves  or  secondary  to  the  influence  of  other  glands  of  in- 
ternal secretion. 

There  are,  however,  numerous  factors  which  influence  the  establishment  of 
the  menses;  one  of  these  is  cHmate.  CHmate  apparently  affects  the  period  of 
puberty  somewhat,  but  not  to  the  extent  formerly  supposed.  It  is  commonljr 
stated  that  in  tropical  regions  menstruation  begins  usually  from  eight  to  nine, 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES  19 

while  in  the  colder  regions  it  is  much  later  than  the  general  average.  Engleman 
has,  however,  showTi  in  extensive  statistics  that  this  is  an  error,  and  that  the 
average  age  of  puberty  is  very  nearly  the  same  in  the  tropics  and  in  the  arctic 
zones — namely,  about  fourteen  and  one-half  j^ears.  In  the  Polar  regions  women 
are  said  to  menstruate  from  two  to  four  times  a  year,  as  a  rule,  and  not  at  all 
during  the  winter  months.  Heredity  plays  a  certain  role,  as  do  general  racial 
characteristics,  but  the  variations  from  these  causes  are  not  wide.  Social 
conditions  also  make  some  difference,  for  statistics  show  that  the  poor  begin 
to  menstruate  later  on  an  average  than  the  well-to-do  and  reach  the  menopause 
earlier.  This  is  thought  to  be  due  to  hard  work  and  poor  nourishment.  It 
has  also  been  observed  that  those  who  live  in  the  country  come  to  puberty 
later  than  those  who  hve  in  the  city,  probably  for  the  same  general  reasons. 
It  must  be  remembered  that  these  figures  have  been  compiled  from  European 
countries,  where  social  conditions  differ  from  those  in  this  country.  Statistics 
on  this  subject  in  America  are  scanty. 

The  duration  of  menstrual  life  is  usually  between  thirty  and  thirty-five  years. 
Kniger's  table  is  as  follows : 

Menopause  at  36^0 12  per  cent. 

Menopause  at  41-45 26    "       " 

Menopause  at  46-50 41    "       " 

iMenopause  at  51-55 15   "       " 

Menopause  before  35  and  after  55 7    "       " 

As  a  rule,  those  in  whom  puberty  comes  early  have  the  menopause  some- 
what later  than  the  normal.     Women  of  this  type  tend  to  menstruate  more 
profusely  and  have  a  special  predisposition  to  myoma  formation,  which  of-^' 
itself  prolongs  menstrual  life. 

Nulliparous  women  and  virgins  reach  the  climacteric  somewhat  sooner  than 
do  parous  women.       « 

Women  of  the  upper  classes  menstruate  distinctly  later  than  women  of  the 
poorer  classes,  the  menopause  of  the  former  averaging  nearer  fifty  than  fortj^- 
five.  Undoubtedly  better  nourishment  and  freedom  from  hard  work  explain 
this  fact. 

It  is  usually  stated  that  the  menopause  appears  earlier  in  hot  chmates 
than  it  does  in  cold.  Statistics  on  this  point  are  conflicting.  It  is  probable 
that  chmate  has  no  very  decided  influence  on  the  menopause,  but  that  in  those 
countries  where  it  appears  abnormally  early  it  is  affected  chiefly  by  the  very 
early  child-bearing  to  which  the  women  are  subjected  and  by  which  they  pre- 
maturely lose  their  bloom. 

When  the  function  of  menstruation  is  estabhshed  it  is  apt  to  be  irregular 
at  first,  but  when  fully  instituted  the  typical  intermenstrual  period  is  from 
twenty-seven  to  thirty-one  days.  There  seems  to  be  a  special  tj'pe  of  women 
who  menstruate  evevy  twenty-three  days.  This  type  is  usually  of  the  class 
who  begin  early  and  have  a  late  climacteric.     It  is  probable  that  in  most  women 


20  GYNECOLOGY 

who  menstruate  every  twenty-one  to  twenty-three  days  there  is  some  under- 
lying pathologic  condition. 

In  healthy  women  the  average  length  of  the  menses  is  three  to  four  days, 
These  limits  may  fluctuate  somewhat  and  still  be  regarded  as  normal.  In 
general,  however,  women  who  menstruate  only  one  or  two  days,  and  those  who 
flow  more  than  five  days  are  not  to  be  regarded  as  entirely  within  physiologic 
limits.  '  ■ 

The  amount  of  blood  lost  at  each  menstruation  has  been  variously  estimated 
by  different  investigators.  It  probably  averages  about  50  gm.  in  the  unmar- 
ried and  somewhat  more  in  the  married  and  parous  (Hoppe-Seilet) . 

Menstrual  blood  is  more  watery  and  paler  than  normal  blood,  and  is  mixed 
with  detritus  and  the  secretions  of  the  uterus,  cervix,  and  vagina. 

The  most  important  characteristic  of  the  menstrual  blood  is  its  non-coagula- 
bility. This  was  formerly  supposed  to  be  due  to  the  influence  of  the  alkahne 
cervical  mucus,  on  the  ground  that  blood  when  alkahne  is  less  coagulable 
than  when  acid.  The  cervical  mucus,  however,  is  probably  not  account- 
able for  the  phenomenon.  Birnbaum  and  Osten  have  shown  that  the  body 
blood  of  a  menstruating  woman  is  only  one-half  as  coagulable  as  it  is  when 
she  is  not  menstruating,  but  this  has  recently  been  denied.  The  change  was 
thought  to  be  due  to  some  agent  which  affects  the  entire  organism  of  the 
woman,  and  was  referred  to  the  influence  of  the  ovarian  secretion.  It  is  now 
supposed  to  be  due  to  a  local  influence  of  the  ovarian  secretion  exerted  on  the 
endometrium. 

During  menstruation  there  is  marked  congestion  of  all  the  pelvic  blood- 
vessels, and  as  a  result  the  uterus  is  larger  and  softer  and  more  compressible. 
The  tubes  and  ovaries  are  also  swollen.  The  external  genitals  exhibit  a  decided 
hyperemia.  The  breasts  are  somewhat  fuller  and  often  tender  and  painful, 
and  in  some  there  is  a  noticeable  enlargement  of  the  thyroid  gland. 

A  few  women  experience  a  special  sense  of  well-being  during  the  menstrual 
period,  but  in  most  women  there  is  a  general  physical  and  mental  depression 
which  is  manifested  in  many  different  ways.  The  nervous  equilibrium  especi- 
ally is  unstable.  There  is  increased  irritabiUty  and  susceptibihty  to  psychic 
excitement.  All  neurotic  tendencies  are  accentuated  and  often  appear  at  this 
time  only.  Headaches  periodically  associated  with  some  particular  time  of 
the  menstrual  period  are  very  common.     (See  also  section  on  Neurology.) 

The  majority  of  women  have  some  form  of  pelvic  discomfort  during  cata- 
menia.  Under  physiologic  conditions  this  may  be  merely  a  sense  of  heavi- 
ness or  pelvic  pressure.  If  there  is  actual  pain,  the  condition  is  one  of  dys- 
menorrhea (g.  v.). 

The  symptoms  of  any  pathologic  process,  especially  of  the  lower  abdomen,, 
like  appendicitis  or  salpingitis,  are  exaggerated  by  the  menstrual  congestion. 

Practically,  all  of  the  functions  of  the  body  may  share  in  the  general  depres- 
sion and  exhibit  symptoms  more  or  less  disturbing.     In  the  digestive  system 


PHYSIOLOGY    OF    THE    UTERUS    AND    OVARIES  21 

there  may  be  loss  of  appetite,  tendency  to  vomiting  and  formation  of  gas  in 
the  intestines,  increased  mucus  from  the  colon,  and  constipation  or  diarrhea. 
The  circulatory  system  may  show  irregular  pulse  and  palpitation  of  the  heart. 
Various  vasomotor  chsturbances  are  frequent,  such  as  hot  flushes,  cold  ex- 
tremities, sweating,  etc.  The  mucous  membrane  of  the  nose  and  throat  is 
often  swollen,  causing  mouth-breathing.  Nose-bleeds  are  frequent.  The 
vocal  chords  become  swollen,  so  that  there  is  a  change  in  the  voice.  Singers 
experience  a  change  in  the  quality  and  trueness  of  their  notes,  and  often  are 
obhged  to  refrain  from  singing  in  pubhc  during  the  menstrual  period.  The 
hearing  is  apt  to  be  less  acute,  while  the  eyes,  too,  maj''  suffer  from  granulation 
of  the  lids,  lessening  of  the  field  of  \dsion,  and  impairment  of  color  sense.  Various 
skin  manifestations  are  common  during  .the  menstrual  period,  examples  of  which 
are  exanthematous  rashes,  herpes  of  the  hps,  urticaria,  acne,  etc. 

The  sexual  impulse  is,  as  a  rule,  increased  just  before  and  just  after  the 
catamenial  flow.  It  is  usually  decreased  during  the  period,  but  may  be  in- 
creased. Some  patients  suffer  pain  and  discomfort  about  half-way  between 
their  periods,  resembhng.  that  which  they  have  at  their  regular  flow.  This 
intermenstrual  pain  is.  usually  due  to  some  pathologic  process,  most  com- 
monly an  intramural  fibroid.  In  other  cases  it  cannot  be  explained  by  any 
anatomic  lesion. 

Precocious  menstruation  relates  to  the  appearan.ce  of  the  menses  in  infants 
of  two,' to  four  years  old,  associated  wdth  abnormal  development  of  the  breasts 
and  external  genitals,  growth  of  pubic  hair,  and  awakening  of  the  sexual  im- 
pulse, usually  shown  by  masturbation.  This  condition  is  the  result  of  abnor- 
malities in  the  glands  of  internal  secretion,  and  is  referred  to  in  detail  in  the 
section  on  the  Internal  Secretory  Organs. 

Vicarious  menstruation  is  a  phenomenon  about  which  little  is  known  but 
which  undoubtedly  occurs  at  times.  Instead  of  the  regular  menstrual  flow, 
bleeding  takes  place  more  or  less  periodical^  from  some  other  organ  of  the 
body,  usually  the  nose.  Other  sites  of  vicarious  bleeding  described  are  the 
hps,  breasts,  lungs,  rectum,  hemorrhoids,  ulcerations,  and  wounds.  Vicarious 
menstruation  from  the  nose  is  sometimes  seen  after  hysterectomy  operations, 
where  an  ovary  has  been  left  in  situ  or  where  a  piece  of  it  has  been  transplanted. 

The  menses  may  be  influenced  to  some  extent  by  psychic  excitement,  especi- 
ally that  due  to  fright  or  anxiety.  In  women  who  menstruate  normally  the 
flow  after  having  started  may  be  Suppressed  by  a  sudden  nervous  shock,  or 
such  a  shock  may  bring  on  the  menses  out  of  the  regular  time.  It  is  a  com- 
mon experience  in  a  gynecologic  clinic  that  women  whose  periods  are  usually 
regular  menstruate  out  of  time  under  the  mental  excitement  of  waiting  for 
operation.  ^Menstruation  is  often  delaj'ed  for  several  days  and  even  a  week 
in  women  who  are  laboring  under  the  fear  of  impregnation,  and  also  in  women 
who,  being  extremely  anxious  to  become  pregnant,  have  their  minds  tensely 
concentrated  on  the  function. 


22  GYNECOLOGY 

The  question  of  performing  pelvic  operations  during  the  menstrual  period 
is  one  of  some  importance  and  one  concerning  which  there  is  difference  of 
opinion.  Some  operators  make  it  a  rule  never  to  operate  at  this  time,  while 
others  pay  little  attention  to  the  matter.  It  is  probable  that  in  the  majority 
of  instances  patients  operated  on  during  the  catamenia  have  a  normal  con- 
valescence, but  occasionally  it  happens  that  a  constitutional  effect  is  pro- 
duced by  the  operation  that  results  in  alarming  symptoms.  These  appear 
within  thirty-six  or  forty-eight  hours  after  the  operation  and  simulate  closely 
the  condition  of  profound  shock.  Patients  in  this  state  have  had  their  abdomens 
reopened  in  the  belief  that  they  were  suffering  from  a  secondary  internal  hem- 
orrhage. The  condition  lasts  for  several  hours  and  then  passes  away.  No 
entirely  satisfactory  explanation  has  been  made  of  this  phenomenon. 

The  effects  of  menstruation  on  the  general  organism  mentioned  above  are 
treated  in  greater  detail  in  other  sections. 

The  Climacteric. — The  menopause  is  usually  a  slow  change  extending  over 
several  months  to  several  years.  Menstruation  in  rare  instances  ceases  abruptly; 
more  commonly  there  is. a  gradual  cessation,  consisting  either  of  a  progressive 
diminution  in  the  amount  of  flow  or  in  a  lengthening  of  the  intermenstrual 
period.  Many  women  before  the  end  of  the  menopause  exhibit  a  greater  pro- 
fuseness  in  the  flow  and  shorter  intermenstrual  periods.  An  increase  of  blood 
during  the  menopause  is  not  to  be  regarded  as  physiologic,  a  misconception 
which  often  leads  to  grave  errors.  The  most  common  pathologic  causes  of 
menorrhagia  at  the  menopause  are  cancer,  fibroids,  and  polyps.  In  many 
cases,  however,  no  definite  anatomic  changes  can  be  discovered,  and  the  bleed- 
ing must  be  referred  to  an  insufficiency  of  contractile  power  on  the  part  of  the 
uterine  musculature.  This  uterine  insufficiency  is  not  normal  or  physiologic, 
for  it  subjects  the  patient  to  a  period  of  semi-invalidism  which  may  last  over 
several  years. 

When  the  menopause  is  established  all  the  genital  organs  undergo  a  process 
of  atrophy,  which  in  extent  varies  greatly  in  different  women.  (For  a  detailed 
description  of  Genital  Atrophy,  see  page  540.) 

Many  women  pass  through  the  menopause  with  little  or  no  trouble  and  this 
may  be  considered  the  norm.  There  are,  however,  certain  constitutional  and 
psychic  disturbances  of  a  quasiphysiologic  nature  which  perhaps  the  major- 
ity of  women  experience  to  a  greater  or  less  extent.  These  may  occur  only  at 
the  time  of  the  actual  menopause,  but  they  may  make  their  appearance  several 
years  before  any  change  takes  place  in  the  function  of  menstruation  and  may 
last  long  after  it  has  ceased. 

The  most  typical  of  these  disturbances  are  hot  flushes,  palpitation,  buzzing 
in  the  ears,  dizzy  feelings,  nervous  irritability,  tendency  to  depression,  various 
forms  of  neuroses,  and  often  serious  psychoses.  It  is  a  common  belief  also  that 
certain  physical  changes  take  place,  such  as  a  deepening  of  the  voice,  appear- 
ance of  hair  on  the  upper  hp  and  chin,  accumulation  of  fat,  and  a  general  coarsen- 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES  23 

ing  of  feature  and  contour.  This  last  so-called  reversion  to  the  masculine  type 
has  been  greatly  exaggerated.  Women  who  have  a  tendency  to  obesity  begin 
to  grow  fat  long  before  the  menopause,  as  a  rule,  while  those  who  eventually 
develop  coarseness  of  feature  show  this  characteristic  as  soon  as  the  bloom  of 
youth  begins  to  pass.  The  appearance  of  hair  on  the  face  in  middle  age  is  not 
a  universal  attribute,  but  only  an  individual  peculiarity,  and  is  merely  evidence 
of  advancing  age.  Women  of  innate  physical  refinement  often  show  a  greater 
delicacy  of  lineaments  as  they  approach  and  pass  the  climacteric. 

The  vasomotor  and  psychic  disturbances  referred  to  above  are  thought  to 
be  the  result  of  the  loss  of  ovarian  secretion.  Doubtless  the  atrophy  of  the 
ovaries  does  account  for  some  of  these  manifestations,  especially  those  of  the 
vasomotor  type,  but  this  influence  has  also  been  greatly  exaggerated.  Severe 
manifestations  of  this  kind  nearly  always  appear  in  individuals  with  well- 
marked  neurotic  predisposition,  while  women  of  the  well-balanced  type  usually 
suffer  little.  As  Walthard  has  pointed  out,  the  so-called  critical  period  of  a 
woman's  life  comes  at  a  time  when  domestic  responsibilities  and  worries  are 
at  their  height,  while  the  consciousness  of  approaching  old  age  and  the  loss  of 
physical  attractiveness  constitutes  a  most  important  factor  in  the  discon- 
tent and  mental  despondency  that  women  of  middle  age,  especially  of  the 
social  classes,  are  wont  to  exhibit. 

Just  before  the  climacteric  there  is  usually  an  increase  of  the  sexual  impulse. 
This  may  last  for  a  considerable  time,  but,  as  a  rule,  it  gradually  diminishes. 

.  After  the  age  of  fifty  or  thereabouts  women  often  undergo  a  complete  change 
in  temperament.  Relieved  of  the  anxieties  of  child-raising,  and  reconciled  to 
the  changes  of  age,  they  acquire  a  mental  and  physical  strength  never  before 
experienced,  and  live  for  a  decade  or  two  the  best  years  of  their  life. 

Physiology  of  Conception.^During  coitus  there  takes  place  a  hypersecre- 
tion of  the  glands  of  the  vestibule  and  of  Bartholin's  glands,  the  evident  pur- 
pose of  which  is  for  lubricating  the  parts.  The  semen  is  deposited  in  the  poste- 
rior vault  of  the  vagina,  which  is  termed  the  receptaculum  seminis,  into  which 
under  normal  conditions  the  cervix  dips.  It  was  formerly  supposed  that  the 
semen  was  received  directly  into  the  cervical  canal,  but  this  cannot  be  so,  as 
the  cervix  normally  points  at  right  angles  to  the  axis  of  the  vagina.  Another 
proof  that  the  semen  does  not  enter  directly  into  the  cervix  is  the  fact  that  in 
retroversion  or  anteflexion,  where  the  cervix  points  in  the  direction  of  the 
canal,  and  in  a  more  favorable  position  for  receiving  the  semen,  conception 
usually  does  not  take  place. 

From  the  receptaculum  seminis  the  spermatozoon  reaches  the  cervical 
canal  chiefly  by  its  own  power  of  locomotion,  but  it  is  undoubtedly  assisted  by 
the  cervix  and  its  mucous  secretion.  During  orgasm  the  cervical  glands  pour 
forth  strings  of  mucus  from  their  ducts,  which,  dipping  into  the  pool  of  semen, 
act  as  channels  for  the  passage  of  the  spermatozoa  into  the  canal.  It  has  been 
claimed  that  "the  cervix  during  orgasm  undergoes  certain  muscular  movements 


24  GYNECOLOGY 

which  serve  to  aspirate  the  semen  into  the  lumen.  The  normal  alkaline  reac- 
tion of  the  cervical  mucus  undoubtedly,  also  plays  an  important  part  in  the 
process,  for  spermatozoa  soon  die  in  the  acid  medium  of  the  vaginal  secretions. 
The  chief  factor  for  motion  in  the  upward  progress  of  the  spermatozoon  is  un- 
questionably its  own  motihty.  As  proof  of  this  is  the  occasional  conception 
that  takes  place  where  the  cervix  has  been  amputated,  in  which  there  is  little 
question  of  cervical  secretion  or  aspirating  movements.  That  the  spermato- 
zoon is  capable  of  .weathering  a  journey  through  acid  secretions  the  length  of 
the  vagina  is  shown  by  the  not  infrequent  cases  of  conception  where  there  has 
been  no  introition. 

It  is  now  well  accepted  that  the  unioii  of  the  spermatozoon  and  ovum  takes 
place  either  at  the  fimbriated  end  of  the  tube  or  on  the  surface  of  the  ovary. 
The  union  of  the  two  germ-cells  (amphimixis)  is  consummated  by  the  success 
of  one  spermatozoon  in  piercing  the  surrounding  envelope  of  the  egg.  Only 
the  head  which  contains  the  nucleus  of  the  male  germ-cell  enters  the  ovum, 
the  tail  breaking  off.  On  the  entrance  of  the  spermatozoon  the  envelope  of 
the  ovum  immediately  becomes  thickened,  preventing  penetration  by  other 
aspirants.  The  impregnated  ovum  is  then  guided  by  the  fimbriae  of  the  tube 
to  the  canal  where  it  is  swept  on  to  the  uterus,  partly  by  the  current  of  the 
cilia  of  the  surface  epithelium  and  partly  by  peristaltic  motions  of  the  tubal 
wall.  The  passage  of  the  ovum  to  the  uterine  canal  occupies  several  days  to 
possibly. a  week.  During  this  time  it  acquires  the  power  of  corrosion,  which 
is  characteristic  of  fetal  tissue,  and  when  it  reaches  the  uterine  canal  it  digs  a 
bed  for  itself  in  the  endometrium  where  it  proceeds  to  develop,  nourished  as  a 
parasite  by  the  mother's  blood.  If  the  passage  into  the  uterine  canal  is  in  any 
way  interrupted  the  egg  sinks  into  the  mucous  membrane  of  the  tube  and 
produces  an  ectopic  pregnancy. 

Orgasm  on  the  part  of  the  woman  is  not  necessary  to  conception,  although 
its  absence  is  often  associated  with  sterihty,  especially  in  cases  of  hypoplasia. 
That  orgasm  and  libido  are  not  essential  factors  in  conception  is  proved  by  the 
frequency  with  which  frigid  women  become  mothers,  and  by  the  recorded 
instances  of  impregnation  during  narcosis. 

Physiologic  Anatomy  of  the  Menstruating  Endometrium. — That  the  uterine 
mucosa  passes  through  definite  cyclic  changes  each  month  is  a  comparatively 
recent  addition  to  our  knowledge,  due  chiefly  to  the  researches  of  Hitschmann 
and  Adler,  who  rediscovered  facts  that  had  already  been  announced  years 
before. 

The  cycle  of  change  is  divided  into  three  phases:  (1)  Premenstrual  con- 
gestion, (2)  period  of  menstruation,  and  (3)  postmenstrual  involution. 

The  premenstrual  congestion  begins  about  ten  days  before  the  expected 
period.  By  this  process  there  is  a  marked  thickening  of  the  mucosa,  due  to 
an  hypertrophy  and  hyperplasia  of  the  endometrial  glands  and  a  transudation- 
and  exudation  into  the  stroma.    The  mucosa  becomes  two  or  three  times  thicker 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


25 


Fig.  1. — Premenstrual  Endometrium. 
Low  power.  At  the  bottom  is  the  muscle  of  the  uterine  wall,  sharply  demarcated  from  the 
endometrium.  The  glands  in  the  deepest  part  of  the  endometrium  are  small,  their  epithelial  cells 
low,  for  this  part  of  the  gland  remains  inactive.  The  stroma  cells  are  small  and  lie  close  together. 
At  the  middle  of  the  endometrium  the  glands  are  dilated,  the  epithelium  wavy,  and  the  epithelial 
cells  swollen  and  actively  secreting  mucus.  The  stroma  cells  are  larger  and  lie  further  apart.  On 
the  right  the  dilatation  of  the  blood-vessels  is  well  shown.  Near  the  top  the  glands  have  the  same 
characteristic  as  at  the  middle,  but  there  is  more  edema  of  the  stroma.  Throughout  there  is  a  slight 
infiltration  with  round  cells. 


26 


GYNECOLOGY 


than  the  normal,  and  may  reach  6  to  7  mm.  in  depth.  The  surface  becomes 
irregular  and  furrowed  as  a  result  of  the  general  swelling  beneath.  At  this 
stage  the  endometrium  resembles  closely  an  early  decidua  vera.  The  stroma 
cells  are  large,  pale  and  swollen,  and  separated  by  the  edematous  exudate. 
The  mucosa  is  distinguished  by  two  fairly  well-defined  layers,  the  deeper  con- 
taining the  dilated  and  hypertrophied  glands,  termed  the  spongy  layer,  and 


^2l. 


^^S" 


Fig.  2. — Premenstrual  Endometrium. 
High  power.     This  drawing  shows  the  enlargement  of  the  nuclei  of  the  epithelial  cells,  which, 
instead  of  being  small  and  lying  at  the  bottom  as  in  inactive  glands,  have  enlarged  and  nearly  fill 
the  cells.     The  cells  crowd  each  other  and  a  papilla  can  be  seen  in  the  central  gland. 


the  outer,  denser,  and  less  glandular  portion,  called  the  compact  layer.  The 
dilated  blood-vessels  (seen  chiefly  between  the  spongy  and  compact  layers)  are 
surcharged  with  blood.  By  diapedesis  and  by  actual  rupture  (rhexis)  blood 
is  poured  into  the  stroma  of  the  mucosa,  and  by  following  the  line  of  least 
resistance  toward  the  surface  forms  subepithelial  hematomas.  It  is  probable 
that  at  this  point  uterine  contractions  force  the  blood  through  the  surface  of 
the  mucosa  into  the  uterine  canal,  marking  the  second  phase  of  the  cycle,  the 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


27 


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Fig.  3. — Premenstrual  Endometrium. 
High  power  of  part  of  a  gland.     This  shows  especially  well  how  the  epithelium  of  the  glands  is 
thrown  out  in  tuft-like  projections  during  this  stage.     The  lower  part  of  the  gland  is  dilated,  while 
the  neck  near  the  surface  is  narrow,  holding  the  secretion  in  the  gland. 


28 


GYNECOLOGY 


menstrual  flow.  The  blood  escapes  into  the  lumen,  partly  through  the  inter- 
stices between  the  epithehal  cells  and  partly  by  actual  rupture  of  the  cell  layers, 
small  clumps  of  which  may  be  desquamated  and  discharged  mixed  with  the 
menstrual  blood. 


errs*  '^.:    ■■■■'■rSS)--'.:.  ••;:.'(<5  ^       -         ./K&(. 


^© 


0 


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^|l^<.s>/'   ^^^z.<^S^%^  s,^^;^.lf  J«^^1' 


Fig.  4. — Premenstetjal  Endomethitjm. 
High  power.  The  glands  are  dilated  and  several  show  invaginations  of  epithelium,  the  begin- 
ning of  one  of  which  is  seen  in  the  lower  left-hand  corner.  The  epithelial  cells  are  swollen,  the  nuclei 
la,rge  and  nearly  filling  the  cells.  The  stroma  cells  are  swollen  and  lie  far  apart,  due  to  edema.  A 
dilated  blood-vessel  is  seen  in  the  upper  right  corner.  A  few  round  cells  are  scattered  through  the 
tissue. 


With  the  cessation  of  the  bleeding  begins  a  regeneration  of  the  mucosa. 
The  secretion  becomes  clearer  and  finally  disappears.  The  mucosa  returns  to 
its  previous  thickness  of  2  or  3  mm.  The  blood-vessels  shrink  to  their  normal 
size,  and  the  extravasated  blood  in  the  stroma  gradually  becomes  absorbed, 
leaving  for  a  time  small  brownish  pigmented  spots.     The  broken  surface  epi- 


PHYSIOLOGY   OF   THE    UTERUS    AND    OVARIES 


29 


thelial  layer  becomes  regenerated  by  the  growth  of  new  cells.  The  hjqjer- 
trophied  glands,  which  during  the  premenstrual  stage  became  lengthened, 
spiral-shaped,  and  distended  with  secretion,  discharge  their  contents  during 
the  period  of  menstrual  flow  and  then  resume  their  original  small  narrow  form 


Fig.  5. — Menstruating  Endometrium. 
Low  power.     At  the  top  the  surface  epithelium  is  gone  on  the  left.     The  glands  throughout 
have  discharged  their  contents  and  collapsed.     The  epithelial  cells  are  still  swollen.     The  stroma  is 
very  edematous  and  infiltrated  with  blood,  especially  on  the  left.     At  the  bottom  the  glands  are  still 
somewhat  dilated,  but  there  is  very  little  edema  of  the  stroma. 


and  straight  direction.  When  the  bleeding  has  ceased,  the  edema  of  the  stroma 
disappears  and  the  pale  swollen  stroma  cells  regain  their  former  appearance. 
The  postmenstrual  regenerative  stage  lasts  about  fourteen  days,  when  the 
rhythmical  changes  in  the  mucosa  begin  anew. 

If  no   menstruation   takes   place,   or,   in   other   words,   if   conception   has 


30 


GYNECOLOGY 


occurred,  the  premenstrual  mucosa  maintains  its  character  and  merges  into  a 
true  decidua. 

It  has  been  shown  that  during  the  cycHcal  change  there  is  an  increasing 
glycogen  production  from  the  mucosa,  which  reaches  its  height  during  the 
menstrual  flow,  after  which  it  disappears,  until  the  premenstrual  stage  begins 
again.  This  glycogen  production  is  undoubtedly  a  provision  for  the  nourish- 
ment of  the  egg. 

During  the  period  of  flow  the  superficial  epithehal  cells  of  the  mucosa  are 
said  to  lose  their  ciha.  These  are  restored  during  the  postmenstrual  regenera- 
tive stage. 


.>%^;. 
I^^/^^ 


■■■•  vXi<":, 


=>5-'')j 


Fig.  6. — Endometrium  At  Beginning  of  Menstruation. 
The  glands,  except  for  the  one  seen  in  the  center,  have  collapsed,  having  discharged  the  mate- 
rial which  was  secreted  during  the  premenstrual   stage.     The  blood-vessels  have  been  eroded  by 
the  ferment  contained  in  the  secretion,  allowing  the  blood  to  exude  into  the  tissue  and  on  the  sur- 
face of  the  endometrium.     The  surface  epithelium  in  this  section  is  still  intact. 


The  cervical  mucous  membrane  takes  no  part  in  the  menstrual  bleeding, 
but  secretes  an  increased  amount  of  mucus.  There  is  a  question  as  to  whether 
the  tubal  mucous  membrane  shares  in  the  bleeding.  It  probably  does  not,  as 
a  rule,  but  there  is  evidence  from  abdominal  operations  done  during  the  men- 
strual period,  where  the  tube  can  be  inspected,  that  there  is  sometimes  an 
associated  tubal  menstruation. 

The  researches  of  Hitschmann  and  Adler  have  been  questioned  to  some 
extent,  but  in  the  main  they  are  now  nearly  universally  accepted. 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


31 


Fig.  7. — -Postmenstrual  Endometrium. 
Low  power.     The  surface  epithelium  is  regenerated.     The  glands  are  still  dilated,  but  the  epi- 
thelium is  low,  the  nuclei  of  the  cells  small  and  lying  at  the  bases.     There  is  some  edema  of  the  stroma 
near  the  top,  but  the  cells  are  smaller,  the  blood-vessels  collapsed.     There  is  a  slight  infiltration  with 
round  cells  and  blood-corpuscles. 

PHYSIOLOGIC  ANATOMY  OF  THE   OVARY^ 

In  our  present  knowledge  of  gynecologic  physiology  the  ovary  has  assumed 
such  a  commanding  position  that  it  is  necessary  to  devote  special  attention  to 
its  functional  anatomy. 

The  ovary  is  covered  by  a  single  layer  of  low  cuboidal  cells,  called  the  ger- 
minal epithehum,  which  unites  with  the  peritoneal  endothelium  in  an  irregular 
line  at  the  hilum.  This  germinal  epithelium  is  emhryologically  continuous  with 
the  epithelium  of  the  tubal  and  uterine  mucosa.  Though  modified  and  appar- 
ently insignificant  in  its  role  as  a  covering  of  the  ovary,  it  nevertheless  has 
extraordinary  potentiahties  for  growth,  and  is  probably  the  chief  factor  in  the 
etiology  of  parenchymatous  ovarian  cysts. 

During  childhood  the  surface  of  the  ovary  is  for  the  most  part  smooth,  but 

^  Chief  authority,  Schroder  in  Opitz  and  Menge. 


32 


GYNECOLOGY 


after  puberty  the  scarring  process  of  ovulation  gives  it  an  irregular  furrowed 
appearance.  Under  the  germinal  epithelium  is  a  thin,  rather  dense  layer  of 
fibrous  tissue,  which  gives  the  ovary  its  whitish  appearance  and  which  is  called 
the  albuginea.  This  structure  is  not  fully  developed  until  the  time  of  puberty, 
and  at  that  time  consists  of  three  layers  of  connective  tissue.  In  old  age  and 
certain  pathologic  conditions  it  becomes  much  thickened,  and  if  abnormally 
thick  may  play  a  part  in  the  causation  of  sterility. 

Beneath  the  albuginea  is  the  parenchymatous  layer,  which  consists  of  a 
characteristic  cellular  connective  tissue  in  which  are  contained  the  follicles. 
Merging  into  the  parenchymatous  layer  is  the  medullary  layer  at  the  hilum, 
through  which  pass  the  blood-  and  lymph-vessels,  nerves  and  connective  tissue, 


Gxrerrvi.Tv&V  epitKeliuirv. 


ToU\CS«.S 


Fig.  8. — Formation  of  Follicles,  from  the  Ovary  of  a  Newborn  Infant. 
Germ-cells  can  be  seen  in  the  outer  germinal  layer  of  epithelium.     The  germinal  epithelium  can 
be  seen  growing  inward  and  eventually  suj^rounding  the  germ-cells  by  a  single  layer  of  cells.     (After 
Kiistner.) 


and  muscle-fibers  from  the  broad  ligament.  In  this  layer  are  found  small 
glandular  ducts,  which  are  by  some  thought  to  be  the  remains  of  the  Wolffian 
ducts  and  are  supposed  to  connect  with  the  parovarium.  A  more  recent 
theory  is  that  they  are  off-shoots  from  the  germinal  epithelium. 

The  follicles  are  confined  exclusively  to  the  parenchymatous  layer.  It  is 
estimated  that  at  birth  the  individual  is  endowed  with  about  30,000  of  these 
follicles,  and  it  is  generally  accepted  at  the  present  time  that  no  new  ones 
are  created  after  birth.  The-*Bsential  function  of  the  ovary  consists  in  the 
development  and  ripening  of  the  follicles.  This  process  begins  verj^^  early, 
probably  at  the  end  of  intra-uterine  life.  Up  to  the  age  of  puberty  the  ripening 
follicles  become  atretic  or  aborted,  and  only  at  that  time  do  they  begin,  to 
develop  into  true  corpora  lutea.     From  puberty  there  is  a  continuous  process 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


33 


of  development  of  the  follicles  until  the  menopause,  when  they  disappear 
entirely. 

In  the  maturing  process  there  are  three  stages  to  be  distinguished:  (1)  the 
primordial  follicle,  (2)  the  ripening  follicle,  and  (3)  the  ripe  Graafian  follicle. 

(1)  The  primordial  follicle  lies  embedded  in  the  stroma  of  the  ovary,  imme- 
diately under  the  albuginea.  It  consists  of  the  naked  egg  surrounded  by  a 
single  layer  of  low  flat  epithelium.  The  primordial  egg  is  an  ellipsoid,  mem- 
braneless  cell  fairly  constant  in  size.  The  cell-body  is  composed  of  a  clear 
protoplasm  in  which  can  be  distinguished  a  very  fine  network.      In  the  cehter 


k%.'^' 


^ 


-^  ft  fr  <^-"*v\ 


i%r 


:*-^ 


> 


^^^  -^-"^ 


Fig.  9.— Primordial  Follicles  from  the  Ovary  of  a  Woman  of  Twenty-five. 
The  central  protoplasmic  mass  is  the  germ-cell  or  egg.     It  is  enveloped  by  a  single  layer  of  epithelium. 

(After  Veit.) 

of  the  body  is  a  round  nucleus  with  a  definite  surrounding  membrane.  The 
nucleus  contains  an  eccentrically  lying  nucleolus,  which  is  not  always  observable 
in  the  fetus  and  newborn,  its  absence  showing  probably  an  immature  stage  of 
development.  The  epithelial  layer  of  the  follicle  has  been  shown  to  be  derived 
from  the  germinal  epithehum  which  surrounds  the  ovary,  and,  as  will  be  seen, 
is  a  structure  of  much  importance.  The  fundamental  function  of  the  ovary 
represents  a  repeated  ripening  of  the  primordial  follicles.  They  can  be  seen 
in  lessening  numbers  up  to  the  time  when  ovulation  ceases  at  the  menopause. 

(2)   The  Ripening  Follicle.— When  the  folHcle  begins  to  ripen  the  surround- 
ing epithehal  cells  begin  to  multiply  by  mitosis  and  to  heap  up  into  several 

3 


34 


GYNECOLOGY 


layers.  The  cells  now  assume  a  larger  and  more  cuboidal  form  and  lie  closely 
around  the  egg.  Soon  in  this  mass  of  cells  there  appears  a  vacuohzation,  or 
clear  space,  which  becomes  filled  with  fluid,  the  so-called  liquor  folliculi.  The 
clear  place  containing  the  liquid  is  crescentic  in  form,  partly  encompassing  the 
egg.  Several  layers  of  epithelial  cells  continue  to  envelop  the  egg,  and  the 
mass  thus  formed  juts  out  into  the  liquor  like  a  peninsula.  The  collection  of 
protecting  cells  that  surround  the  egg  is  called  the  discus  "proligeriis  (or  cumulus 
oophorus),  while  the- rest  of  the  epithelium  around  the  periphery  of  the  follicle 
is  called  the  membrana  granulosa. 


Fig.  10. — Graafian  Follicle. 
High  power.     Three  foUicles  are  seen  which  are  in  the  earliest  stages.     The  center  one  has 
begun  to  show  proHferation  of  the  cells.     These  cells  were  originally  derived  from  the  germinal  epi- 
thelium covering  the  ovary.     No  ova  are  seen. 


At  the  same  time  that  these  changes  are  going  on  inside  the  follicle,  it  is 
being  surrounded  on  the  outside  by  a  concentric  envelope  of  connective  tissue, 
termed  the  theca  folliculi.  This  envelope  is  plainly  divided  into  two  layers, 
that  lying  farthest  away  from  the  follicle  being  termed  the  tunica  or  theca  ex- 
terna, and  that  lying  next  to  the  follicle  being  called  the  tunica  or  theca  interna. 
The  tunica  externa  is  thick  and  dense  and  consists  of  circularly  arranged 
connective-tissue  fibers.     It  contains  the  blood-  and  lymph- vessels  that  supply 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


35 


t«pi 


y/ 


'Vi\" 


Fig.  11. — Early  Development  of  the.  Follicle. 
On  the  left  are  two  primordial  follicles,  the  upper  showing  the  egg  and  surrounding  follicle  epi- 
thelium ;  the  lower  showing  the  manner  in  which  the  follicle  epithelium  completely  surrounds  the  egg. 
The  middle  picture  shows  the  earliest  stage  of  ripening  in  which  the  follicle  epithelium  multiplies 
into  several  layers.  The  third  picture  shows  a  further  development  of  the  follicle  epithelium  and  the 
beginning  of  the  crescentic  clear  space  containing, the  liquor  folliculi.     (After  Bumm.) 


b'd 


o 


& 


,f?© 


Fig.  12. — Graafian  Follicle  from  the  Ovary  of  a  Newborn  Infant. 
The  clear  space  around  the  layer  of  epithelium  is  the  result  of  an  artefact  in  preparing  the  section. 

(After  von  Winckel.) 


36 


GYNECOLOGY 


the  follicle.  The  tunica  interna  is  also  composed  of  connective  tissue,  but  is 
much  more  cellular  than  the  externa.  These  cells  are  large  and  rich  in  proto- 
plasm and  are  epithelioid  in  character.  Toward  the  end  of  the  ripening  stage 
they  are  actually  larger  than  the  epithelial  cells  of  the  membrana  granulosa. 

Meanwhile  the  egg  also  undergoes  a  change.  It  becomes  surrounded  by  a 
strong  homogeneous  capsule,  the  zona  pellucida.  The  protoplasm  of  the  egg 
does  not  come  in  direct  contact  with  the  zona  pellucida,  there  being  between 
the  two  the  so-called  perivitelhne  space,  which  contains  fluid  and  in  which  the 


t' 


m 


^ 


■^J/J^ 


m 


i  ^§, 


■^ 


'i>    (.  ^  ^  ^^"^  M 


Fig.  13. — Graafian  Follicle. 
High  power.     In  the  center  of  the  drawing  is  a  follicle  undergoing  development.     In  the  center 
of  the  follicle  is  the  ovum,  which  is  surrounded  by  layers  of  cells  constituting  the  membrana  granulosa. 
The  theca  f oUiculi  is  not  differentiated  as  yet.     To  the  lower  left  side  are  two  primordial  follicles. 


egg  enjoys  a  free  movement.  As  the  follicle  develops  the  crescentic  lake  con- 
taining the  liquor  folliculi  becomes  more  and  more  filled  with  fluid,  which  forms 
from  a  transudation  of  the  vessels  of  the  theca  and  from  vacuolization  of  the 
granulosa  cells.  It  is  a  thin  serous  fluid  containing  albumin  and  is  undoubt- 
edly a  source  of  nourishment  for  the  egg.  The  egg  surrounded  as  it  is  by  several 
radiating  layers  of  granulosa  cells  (the  discus  proligerus)  does  not  come  in  direct 
contact  with  this  fluid,  but  evidently  receives  nourishment  from  it  through  the 
medium  of  a  fine  intercellular  network  (paladinos),  the  fibrils  of  which  reach 
the  zona  pellucida. 


PHYSIOLOGY    OF   THE    UTERUS    AND    OVARIES 


37 


The  follicle  as  it  grows  larger  recedes  from  the  albuginea,  and  lies  more 
deeply  embedded  than  do  the  primordial  follicles. 

When  the  changes  described  above  are  completed  the  follicle  is  said  to  be 
ripe,  and  at  this  stage  it  is  termed  a  Graafian  follicle.  Up  to  the  time  of  the 
menopause  foUicles  in  all  stages  of  development,  from  the  primordial  to  the  rip- 
ened form,  may  be  seen  in  the  ovarian  parenchyma.  In  all  the  follicles,  even 
the  smallest,  nmnerous  nerve-fibers  accompany  and  surround  the  capillary 
vessels,  extending  to  the  folhcle  epithelium  and  existing  in  small  nodes  in  the 
membrana  granulosa  of  the  larger  follicles. 


Fig.  14. — Ripening  Follicle  from  an  Ovary  of  a  Woman  of  Twenty.     (After  Veit.) 


In  some  of  the  follicles  can  be  seen  two  and,  rarely,  three  eggs.  This  appear- 
ance is  usually  seen  in  the  unripe  follicles.  It  is  not  known  whether  this  appear- 
ance represents  twin  eggs  from  the  start,  or  whether  it  signifies  a  merging  of  two 
primordial  follicles  or  a  division  of  one  follicle. 

(3)  The  Graafian  Follicle. — When  the  follicle  is  ripe  it  moves  slowly  toward 
the  surface  and  thins  out  the  outer  layer  of  the  ovary.  This  pressure  on  the 
surface  of  the  ovary  creates  a  pale  translucent  spot,  called  the  stigma,  through 
which  the  egg  is  finally  discharged. 

The  internal  force  which  serves  to  burst  the  follicle  is  a  subject  of  some 
debate.      It  is  usually  explained  as  follows:  With  the  energetic  development 


38 


GYNECOLOGY 


of  thre  vessels  of  the  tunica  externa  there  is  a  corresponding  increase  in  the  size 
'  and  number  of  the  cells  of  the  tunica  interna,  which  force  themselves  toward  the 
center  of  the  follicle  and  gradually  push  the  proligerus  with  its  egg  toward  the 
stigma.  The  internal  force  is  also  enhanced  by  the  gradual  increase  in  the 
amount  of  liquor  in  the  follicle,  especially  during  the  menstrual  congestion. 

Corpus  Luteum. — When  the  follicle  has  ruptured  and  the  egg  discharged  the 
formation  of  the  corpus  luteum  begins.  The  center  of  the  collapsed  follicle 
soon  fills  with  blood,  which  issues  partly  from  the  vessels  of  the  theca  and 


Fig.  15. — Graafian  Follicle. 
Surrounding  the  follicle  can  be  seen  the  two  connective- tissue  envelopes,  the  outer  (theca  externa) 
being  fibrous  in  character  and  the  inner  (theca  interna)  being  more  cellular.  The  egg  is  seen  jutting 
out  into  the  clear  space  surrounded  by  a  mass  of  epithelial  cells,  the  discus  (or  cumulus)  proligerus. 
The  several  layers  of  epithelium  lining  the  follicle  constitute  the  membrana  granulosa.  The  crescen- 
tic  clear  space  is  filled  with  serous  fluid,  the  liquor  foUiculi.     (After  Veit.) 

partly  from  the  small  wound  in  the  stigma.     In  animals  this  blood  coagulum  is 
not  always  seen,  but  it  is  practically  constant  in  the  human  corpus  luteum. 

Around  the  central  blood-mass  is  the  wrinkled  yellow  membrane  which 
characterizes  the  corpus  luteum  by  its  unique  color.  There  has  been  some 
question  as  to  the  origin  of  the  cells  that  make  up  the  yellow  membrane,  but  it 
is  now  generally  accepted  that  they  represent  the  hypertrophied  epithehal 
cells  of  the  membrana  granulosa.  They  are  large  and  polymorphous,  with  a 
large  nucleus,  and  resemble  somewhat  decidual  cells.  The  cell-body  contains 
drops  of  fat  and  yellow  pigment  granules  that  give  the  characteristic  color. 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


39 


These  are  the  so-called  lutein  cells.  Into  this  lutein  layer  sprout  blood-vessels 
and  connective-tissue  radial  projections,  which  vascularize  and  support  the 
corpus  luteum.  The  resultant  picture  of  large  epithehal  cells,  with  pale  stain- 
ing nuclei  lying  in  contact  with  small  thin-walled  blood-vessels,  corresponds  to 
the  structural  appearance  commonly  regarded  as  characteristic  of  organs  of 
internal  secretion.  As  will  be  seen,  this  is  one  of  the  arguments  for  the  belief 
that  the  seat  of  the  internal  secretion  of  the  ovary  is  in  the  corpus  luteum. 


-»:^ 


>^^«i!|><i'.. 


i9i> 


Fig.  16. — Graafian  Follicle  as  it  Appears  in  the  Surrounding  Ovarian  Tissue. 
Just  below  the  follicle  is  a  corpus  albicans. 


After  the  corpus  luteum  reaches  the  height  of  its  development  it  gradually 
shrinks.  The  yellow  coloring  matter  is  absorbed  and  the  lutein  cells  degen- 
erate in  hyalin  masses,  held  together  by  strands  of  connective  tissue.  The 
hyalin  colorless  masses  then  roll  together  in  cloud-like  convolutions  and  form 
the  corpus  albicans.  This  process  of  regression  occupies  about  four  weeks. 
The  corpus  albicans  may  remain  a  long  time,  but  the  hyahn  material  is  event- 
ually entirely  absorbed  and  all  trace  of  the  former  corpus  luteum  disappears, 
excepting  the  scarred  indentation  on  the  surface  of  the  ovary. 

The  size  of  the  corpus  luteum  varies  considerably,  reaching  sometimes  even 


40 


GYNECOLOGY 


in  non-pregnant  women  a  diameter  of  2  cm.  If  pregnancy  occurs  its  develop- 
ment is  more  pronounced,  reaching  its  height  about  the  second  month.  From 
the  third  month  its  regression  is  very  slow,  so  that  it  is  sometimes  demon- 
strable at  the  end  of  pregnancy. 

If  pregnancy  is  not  present,  the  corpus  luteum  regresses  rapidly  and  is 
usually  shrunken  by  the  end  of  a  month. 

Follicle  Atresia. — In  the  thirty  to  thirty-five  j'-ears  of  menstrual  hfe  about 
fourteen  to  eighteen  folhcles  reach  full  maturity  each  year,  making  a  total  of 


Fig.  17. — Graafian  Follicle,  Well  Advanced. 


400  to  600  during  a  life  time.  Inasmuch  as  there  is  an  original  endowment  of 
about  30,000  follicles  at  birth,  only  a  small  percentage  of  them  develop  com- 
pletely, the  remainder  becoming  aborted  during  some  stage  of  their  develop- 
ment, a  process  that  is  called  atresia  of  the  follicle.  This  process  must  be  re- 
garded as  a  physiologic  one,  beginning  as  it  does  in  the  newborn  and  probably 
in  the  mature  fetus  and  lasting  until  the  menopause. 

The  cause  of  atresia  is  thought  to  be  some  insufficiency  of  the  local  blood- 


PHYSIOLOGY  OF  THE  UTERUS  AND  OVARIES 


41 


supply,  or  a  too  deep  embedding,  which  may  be  unfavorable  for  the  bursting  of 
the  follicle. 

Follicle  atresia  takes  place  in  the  follo\ving  way: 

The  egg  slowly  undergoes  a  fatty  degeneration  and  becomes  liquefied. 
The  granulosa  cells  also  degenerate  by  the  process  of  Vacuolization  and  fall  into 
the  central  cavity  of  the  follicle.  The  entire  follicle  collapses  and  assumes  an 
irregular  contour.     At  this  stage  the  cells  of  the  tunica  interna  begin  to  grow 


Fig.  18. — Graafian  Follicle. 
Low  power.  This  shows  the  edge  of  a  fully  developed  follicle.  The  upper  left  part  of  the  draw- 
ing is  the  cavity  in  the  follicle.  At  the  lower  right  edge  projecting  into  this  cavity  is  the  cumulus 
proligerus,  consisting  of  cells  from  the  membrana  granulosa,  which  lines  the  cavity,  in  the  center  of 
which  is  the  ovum.  At  the  bottom  of  the  drawing  can  be  seen  a  small  section  of  ovarian  stroma. 
Between  this  and  the  follicle  is  the  connective  tissue  of  the  theca  folliculi. 

and  assume  an  epithelioid  type,  resembling  closely  the  lutein  cells  of  the  mem- 
brana granulosa.  This  theca  membrane  may  become  quite  thick  and  wavy, 
like  that  of  the  granulosa.  As  in  the  true  corpus  luteum  there  is  a  vascu- 
larization and  connective-tissue  formation,  so  that  the  resulting  picture  is  the 
same  as  that  of  the  corpus  luteum,  the  essential  difference  being  that  the  lutein 
cells  are  of  connective-tissue  origin,  and  not  epithelial. 

FolUcle  atresia  is  especially  marked  during  pregnancy.  During  this  period  there 
is  no  actual  ovulation,  so  that  most  of  the  more  mature  follicles  become  atretic. 


42 


GYNECOLOGY 


It  is  said  that  during  pregnancy  there  takes  place  in  the  theca  lutein  cells 
of  the  atretic  follicles  not  only  hypertrophy  but  hyperplasia,  and  that  the 
cells  acquire  more  fat  and  lutein  than  is  seen  in  the  non-pregnant  state.  In 
chorio-epithelioma  and  tubal  gestation  they  sometimes  form  definite  cysts  which 
later  disappear. 

In  some  species  of  animals  the  collections  of  theca  lutein  cells  embedded  in 
the  stroma  form  a  constant  picture.     These  masses  of  cells  have  been  called 


TvA^'^" 


Fig.  19.— Corpus  Luteum. 
Low  power.  At  the  top  is  the  center  of  the  corpus  luteum,  the  edge  seen  being  the  edge  of  the 
blood-clot.  Extending  into  this  blood-clot  are  seen  the  pyramids  formed  of  lutein  cells,  giving  the 
edge  of  a  corpus  luteum  its  characteristic  ruflSed  appearance.  Between  these  two  layers  is  a  thin 
layer  of  connective  tissue.  Below  the  layer  of  lutein  cells — that  is,  around  the  outside  of  the  corpus 
luteum — is  the  theca  externa,  which  contains  many  blood-vessels. 


the  interstitial  gland,  and  correspond,  as  said  above,  to  the  lutein  cells  of  the 
atretic  folhcles.  They  are  thought  by  some  to  play  a  part  in  the  manufacture 
of  the  internal  secretion  of  the  ovary. 

Two  forms  of  follicle  atresia  are  distinguished — the  obliterating  and  the 
cystic.  Cystic  formation  in  the  ovaries  is,  therefore,  physiologic.  The  cysts, 
however,  may  grow  to  an  abnormal  size  and  become  of  pathologic  significance. 
(See  Retention  Cysts.) 


Fig.  19(1. — Corpus  Luteum. 
Very  low  power.     Around  the  edge  is  the  pUcated  envelope  of  lutein  cells.     The  center  is  occu- 
pied by  coagulated  blood,  around  the  edge  of  which  the  lutein  cells  are  proliferating.    Organization 
of  the  blood-clot  is  going  on. 


Fig.  20. — Wall  of  Corpus  Luteum. 

High  power.     This  shows  the  pigment  found  in  the  lutein  cells,  which  gives  them  their  distinctive 

yellow  color.     It  is  derived  from  the  blood  extravasated  during  rupture  of  the  follicle. 

43 


Relationship  of  gynecology  to  the  General  organism 

relationship  of  gynecology  to  the  glands 
of  internal  secretion 

The  study  of  the  internal  secretory  organs  has  assumed  so  great  an  impor- 
tance that  a  famiharity  with  the  subject  is  essential  in  the  study  of  every  branch 
of  medical  science.  This  is  eminently  true  of  the  department  of  gynecology, 
for  the  female  organism  is  peculiarly  susceptible  to  physiologic  and  pathologic 
changes  in  the  general  endocrine  system.  Much  of  our  knowledge  gleaned  from 
the  vast  store  of  experimental  and  clinical  observation  in  this  new  line  of  research 
is  so  contradictory  and  confusing  that  space  will  not  permit  a  comprehensive 
review  of  the  subject.  It  will  be  necessary,  therefore,  to  devote  our  attention 
chiefly  to  those  facts  that  are  most  convincing  and  most  generally  accepted, 
with  especial  reference  to  the  phases  of  the  subject  wliich  relate  particularly  to 
the  generative  system. 

The  essential  glands  of  internal  secretion  may  be  defined  as  ductless  struc- 
tures which  by  the  agency  of  certain  cellular  elements  manufacture  chemical 
substances,  called  hormones,  that  are  absorbed  directly  into  the  blood-circulation 
and  by  this  means  are  enabled  to  influence  the  functions  of  other  organs. 

The  term  internal  secretion  is  necessarily  used  in  a  somewhat  restricted  sense. 
Broadly  speaking,  each  tissue  of  the  body  by  means  of  its  specific  chemical 
secretions  is  capable  of  affecting  through  the  blood-stream  other  parts  of  the 
body. .  In  this  sense  the  entire  organism  may  be  regarded  as  forming  a  complex 
internal  secretory  system.  The  subject,  however,  is  confined  to  the  considera- 
tion of  a  series  of  organs  which  produce  hormones  with  especially  powerful  and 
important  physiologic  characteristics.  This  series  of  organs  constitutes  the 
ductless  glandular  system .  and  comprises  the  thyroid  apparatus,  the  thymus 
gland,  the  suprarenal  system,  the  hypophysis  cerebri  or  pituitary  body,  the 
epiphysis  or  pineal  body,  the  generative  glands,  the  pancreas,  and  a  few  other 
organs,  such  as  the  kidneys,  the  intestinal  and  gastric  mucosa.  To  this  list  the 
placenta  has  recently  been  added. 

Although  by  the  internal  secretory  theory  the  influence  of  distant  organs  on 
each  other  is  based  on  a  chemical  reaction  instead  of,  as  was  formerly  believed, 
on  a  direct  nervous  relationship,  the  nervous  system  nevertheless  plays  an  impor- 
tant part,  for  many  of  the  phenomena  produced  by  the  internal  secretions  are 
brought  about  by  chemical  action  on  the  sympathetic  or  vegetative  system  of 
nerves.  The  glands  of  internal  secretion  are  themselves  supplied  by  sympathetic 
nerves  and  their  function  is,  therefore,  in  large  part  regulated  by  the  nervous 
system.  The  intimate  relationship  between  the  ductless  glands  and  the  sym- 
pathetic nerves  is  especially  significant  from  a  gynecologic  standpoint  on  account 

44 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM        45 

of  the  peculiarly  sensitive  and  labile  character  of  the  female  nervous  organiza- 
tion.    It  is  known,  for  example,  that  the  generative  organs  exercise  a  particular 
influence  on  the  tone  of  the  vegetative  organs  {i.  e.,  organs  that  are  supphed  by 
sympathetic  nerves),  an  influence  which  is  more  marked  in  women  than  in  men. 
This  is  most  noticeable  at  the  so-called  critical  periods  of  a  woman's  life.     At 
the  menstrual  period  and  during  pregnancy  there  takes  place  an  increased  ex- 
citability of  all  the  vegetative  functions,  which  may  be  manifested  either  by  an 
accentuated  vitality  or  by  various  deviations  from  the  normal.     During  the 
climacteric,  when  the  generative  glands  cease  then-  function,  the  influence  of  the 
internal  secretions  on  the  vegetative  system  makes  itself  apparent  by  temporary 
vasomotor  disturbances  of  a  most  varied  character.     At  the  time  of  puberty 
there  takes  place  a  most  important  increase  in  the  vegetative  functions,  the 
change  being  more  marked  in  girls  than  in  boys.     In  all  these  instances  the  in- 
fluence on  the  sympathetic  system  is  due  not  alone  to  the  internal  secretion  of  the 
generative  glands,  but  in  part  to  the  correlated  action  of  the  other  ductless  organs. 
The  theory  of  a  correlation  between  the  glands  that  constitute  the  endocrine 
system  though  only  vaguely  understood  is,  nevertheless,  essentially  well  estab- 
hshed.     It  may  be  stated  in  general  that  the  ductless  glands  are  normally  so 
correlated  as  to  form  a  perfect  physiologic  balance  which  is  preserved  by  a  proper 
distribution  of  harmony  and  antagonism  between  the  functions  of  the  various 
glands.     If  one  of  the  glands  is  diseased  or  injured  or  extirpated  the  normal 
balance  is  upset  and  the  organism  of  the  individual  may  be  affected  by  the  ab- 
normal action  of  one  or  more  distant  glands  of  the  group.     The  reciprocal  dis- 
turbance created  in  a  given  gland  by  the  abnormality  of  another  member  of  the 
system  is  often  referred  to  as  dysfunction.     Such  dysfunction  probably  does  not 
constitute  an  alteration  in  the  chemical  composition  of  the  secretion  of  the  gland 
in  question,  but  rather  imphes  a  change  in  the  amount,  that  is  to  say,  a  diminu- 
tion or  an  accentuation  of  the  secreted  substance.     Changes  in  glandular  activity 
of  this  kind  are  also  referred  to  as  hypo-  and  /njperfunctional.     The  reciprocal 
action  of  the  different  ductless  glands  and  of  their  various  secreting  parts  during 
a  given  upset  of  balance  is  of  an  exceedingly  complex  nature,  and  in  our  present 
state  of  knowledge  is  only  partially  understood. 

It  was  first  thought  that  an  internal  secretion  could  only  be  elaborated  by 
epithelial  elements.  The  histologic  type  of  internal  secretory  structure  was 
described  as  consisting  of  relatively  large,  pale,  not  sharply  defined  epithelial 
tissue  containing  a  rich  network  of  capillary  blood-vessels  which  carry  off  into  the 
circulation  products  of  the  cell  activity.  This  description  is  appUcable.to 
certain  of  the  internal  secretory  tissues,  but  it  has  been  discovered  that  structures 
of  connective-tissue  origin  are  also  capable  of  manufacturing  an  internal  secretion, 
and  that  in  one  and  the  same  organ  epithelial  and  connective-tissue  elements 
may  be  working  side  by  side,  each  elaborating  secretions  destined  for  separate 
purposes.  Examples  of  this  are  seen  in  the  hypophysis,  the  suprarenals,  and,  the 
ovaries. 


46  GYNECOLOGY 

OVARY  1 

That  the  ovary  is  a  true  organ  of  internal  secretion  is  proved  by  very  sub- 
stantial evidence  gained  from  observations  made  after  removal,  and  from 
transplantation  of  ovarian  tissue,  and  by  the  effects  of  the  injection  into  the 
tissues  of  ovarian  substance.  Castration  before  sexual  maturity  causes 
a  failure  of  genital  development,  while  in  adult  life  it  produces  immediate 
regressive  changes  in  the  uterus,  vagina,  and  external  genitals,  manifested  by 
well-marked  atrophy  of  the  parts.  It  has  been  shown  by  animal  experimenta- 
tion (Halban)  that  this  genital  atrophy  can  be  inhibited  after  castration  by 
transplanting  the  extirpated  ovary  in  distant  parts  of  the  body,  and  if  this 
operation  is  done  on  young  animals  the  other  genitals  may  develop  normally. 
It  has  also  been  shown  in  animals  that  castration  prevents  rut,  but  that  later 
implantation  of  ovarian  tissue  may  reproduce  the  manifestations  of  rut  (Halban) . 

An  observation  of  much  practical  importance  (as  we  shall  see  later)  shows 
that  the  injection  of  ovarin  in  virgin  animals  creates  changes  of  hyperemia  and 
secretion  in  the  internal  and  external  genitals  similar  to  those  which  occur 
during  rut. 

These  are  only  a  few  examples  of  numerous  experiments  that  prove  the 
existence  of  an  ovarian  internal  secretion. 

The  exact  nature  of  the  ovarian  secretion  has  not  been  determined,  nor  is  it 
conclusively  known  in  what  part  of  the  ovarian  tissue  the  substance  is  manu- 
factured. It  seems  probable  that  different  portions  of  the  ovary  elaborate 
substances  which  have  specific  functions.  There  are  two  anatomic  structures 
which  may  most  reasonably  be  expected  to  be  sources  of  hormones — the  corpus 
luteum  and  the  follicle  apparatus. 

Inasmuch  as  ovarian  secretion  is  known  to  exist  before  puberty,  as  proved 
by  the  changes  in  development  after  castration  before  maturity,  it  seems  likely 
that  the  follicle  apparatus  must  be  the  seat  of  manufacture,  for  the  corpus  luteum 
does  not  appear  normally  until  sexual  maturity.  It  is  probable,  therefore,  that 
the  follicle  apparatus  presides  over  the  growth  and  nutrition  of  the  genitals  and 
that  it  influences  directly  or  indirectly  the  general  bodily  development  of  the 
individual.  The  true  nature  and  extent  of  the  influence  of  the  growing  follicles 
are  not  known.  Theories  as  to  the  internal  secretory  power  of  the  atretic  follicles 
are  given  below. 

In  addition  to  the  follicle  apparatus,  the  corpus  luteum  has  been  shown 
to  be  the  probable  seat  of  manufacture  of  important  ovarian  secretion.  As 
has  been  described  in  detail  (see  page  38),  the  corpus  luteum  forms  within  the 
follicle  cavity  after  the  discharge  of  the  ovum,  and  is  derived  from  the  epithelial 
(granulosa)  cells  Hning  the  follicle.  In  its  full  development  the  corpus  luteum 
presents  the  characteristic  picture  of  an  internal  secretory  gland,  with  large 
pale  cells  lying  in  close  proximity  to  thin-walled  blood-vessels,  an  appearance 

1  Some  of  the  material  in  this  section  is  taken  from  articles  by  the  author  published  in  the  Amer- 
ican Journal  of  Obstetrics,  1913,  and  in  the  Journal  of  the  American  Medical  Association,  1917. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       47 

much  like  that  of  the  adrenals.  The  corpus  luteum  does  not  develop  until  the 
age  of  puberty,  and  coincident  with  its  appearance  come  the  cyclical  changes  of 
menstruation  and  the  possibility  of  fecundation,  phenomena  which  disappear 
after  the  cessation  of  corpus  luteum  formation  at  the  climateric. 

That  the  corpus  luteum  is  an  organ  of  internal  secretion  was  first  suggested 
by  Gustav  Born,  who,  after  studying  the  corpus  luteum  verum  of  pregnancy, 
expressed  the  opinion  that  in  histologic  structure  it  corresponds  to  an  internal 
secretory  organ,  and  that  it  probably  presides  over  the  implantation  and  develop- 
ment of  the  fertilized  egg  in  the  uterus.  Fraenkel  supported  the  theory  of  Born 
by  experimental  work  and  attributed  new  physiologic  functions  to  the  corpus 
luteum;  namely,  the  increase  of  the  uterus  at  the  time  of  puberty  as  well  as 
its  cyclical  hyperemic  changes  of  menstruation.  Fraenkel  concluded  that  the 
effect  of  the  internal  secretions  of  the  corpus  luteum  is  a  preparation  of  the  uterus 
for  the  insertion  and  development  of  the  fertilized  egg,  menstruation  taking  place 
in  case  of  failure  of  impregnation.  Notwithstanding  considerable  opposition 
to  many  of  Fraenkel's  views,  it  is  at  present  almost  universally  accepted  that 
the  corpus  luteum  is  an  organ  of  internal  secretion,  though  the  knowledge  of  its 
specific  action  is  incomplete. 

Recent  work  by  Leo  Loeb  has  added  valuable  information  regarding  the 
corpus  luteum  as  an  organ  of  internal  secretion.  He  has  confirmed  by  experi- 
ments the  theory  that  the  corpus  luteum  inhibits  ovulation,  and  has  shown 
experimentally  that  ovulation  may  be  accelerated  by  the  removal  of  the  corpus 
luteum.  The  absence  of  ovulation  during  pregnancy  is  thus  thought  to  be  due 
to  the  continued  presence  of  the  corpus  luteum.  Loeb's  niost  important  con- 
tribution has  been  to  demonstrate  by  animal  experimentation  the  power  of 
growth  which  the  corpus  luteum  has  over  the  uterus.  He  has  shown  that  the 
corpus  luteum  elaborates  a  substance  which  has  a  sensitizing  action  on  the 
uterus.  In  the  non-pregnant  animal  a  sHght  decidual  reaction  is  produced  in 
the  uterine  mucosa  which  recedes  in  a  short  time  as  the  corpus  luteum  retro- 
gresses. In  the  pregnant  animal  the  decidual  reaction  is  much  more  marked 
and  remains  permanent  during  pregnancy  in  the  form  of  the  so-called  maternal 
placenta  (i.  e.,  decidua).  This  continued  reaction  is  the  result  of  the  persistence 
of  the  corpus  luteum  and  to  the  irritation  of  the  growing  ovum,  as  is  proved  by 
Loeb's  experiments.  If  the  uterus  of  a  non-pregnant  animal  is  incised  or  the 
mucosa  mechanically  irritated  at  the  time  during  which  the  corpus  luteum  is 
elaborating  its  ''growth  substance"  a  very  marked  decidual  reaction  is  produced 
in  the  uterine  mucosa,  forming  what  Loeb  terms  a  deciduoma  or  maternal 
placenta.     Such  deciduomata  are  short  hved  in  the  non-pregnant  animal. 

Decidual  reaction  (q.  v.)  is  therefore  undoubtedly  dependent  on  the  internal 
secretion  manufactured  by  the  corpus  luteum.  In  guinea-pigs  and  in  rabbits 
this  reaction  is  producible  only  in  the  stroma  of  the  uterine  mucosa.  In  these 
animals  extra-uterine  pregnancy  experimentally  created  does  not  cause  a  decidual 
reaction  in  the  stroma  of  surrounding  tissues  as  is  seen  in  the  human  female 


48  GYNECOLOGY 

(see  Ectopic  Pregnancy).  Loeb  suggests,  with  good  reason,  ''that  the  difference 
in  the  readiness  with  which  extra-uterine  pregnancy  develops  in  different  species 
depends  in  part  at  least  upon  the  readiness  with  which  the  stroma  of  the  host 
responds  with  the  production  of  a  decidua  favorable  for  the  development  of  the 
embryo." 

That  the  corpus  luteum  is  not  the  sole  source,  or  even  the  most  important 
source,  of  the  internal  secretion  of  the  ovary  is  sufficiently  evident  from  the  fact 
that  during  the  period  of  life  of  sexual  immaturity  in  which  the  internal  secretion 
is  performing  its  most  important  function  of  body  formation,  the  corpus  luteum 
is  wanting.  It  is  necessary,  therefore,  to  seek  in  some  place  in  the  ovary  other 
than  the  corpus  luteum  for  the  primary  source  of  the  internal  secretion. 

There  are  found  in  the  ovary  certain  connective-tissue  cellular  elements, 
termed  "interstitial  cells,"  corresponding  morphologically  to  the  cells  of  Ley  dig, 
which  are  generally  behoved  to  constitute  the  source  of  the  internal  secretion  in 
the  testicle.  These  interstitial  cells  of  the  ovary  occur  in  different  form  in  dif- 
ferent species  of  mammals.  They  correspond  in  histologic  structure  to  the  cor- 
pus luteum  cells,  being  large  and  polyhedral  in  form,  with  granular  protoplasm 
in  which  fat-like  granules  are  embedded.  The  nucleus  is  relatively  small,  usually 
acentric,  and  is  poor  in  chromatin.  The  cells  have,  like  lutein  cells,  a  yellow 
tint,  and  in  this  way  resemble  the  interstitial  cells  of  the  testicle  of  many  species. 
Just  as  in  lutein  cells  and  in  the  cells  of  Leydig,  mitotic  figures  are  not  seen 
(Tandler  and  Gross). 

The  existence  of  the  interstitial  cells  has  long  been  recognized,  having  first 
been  discovered  by  Pfiliger  in  1863,  who  demonstrated  them  in  the  ovaries  of 
cats  and  dogs.  Successive  investigators  found  the  cells  in  numerous  species  and 
finally  in  apes  and  in  human  beings.  It  was  found  that  they  occur  with  great 
inconstancy,  in  some  species  appearing  in  separate  gland-like  masses,  in  others 
as  scattered  cells.  They  also  exhibit  marked  variations  in  the  same  species. 
Thus,  in  the  embryo  of  the  horse  the  interstitial  cells  are  strongly  developed, 
while  toward  the  period  of  birth  they  become  gradually  less  well  defined  (Born) . 
In  some  species  they  increase  at  the  time  of  sexual  maturity  and  then  diminish 
with  age.  In  other  animals  they  are  most  prominent  during  the  spring  of  the 
year  or  during  the  season  of  rut.  In  still  others  they  are  affected  by  environ- 
mental changes,  such  as  long-continued  isolation.  More  recent  investigation 
has  shown  that  the  interstitial  cells  become  more  highly  developed  after  roent- 
genization  of  the  ovaries,  while  in  the  male  the  homologous  cells  of  Leydig 
undergo  a  like  development  as  a  result  of  vasectomy.  These  observations  have 
paved  the  way  for  valuable  experiments  which  have  added  much  to  our  knowledge 
of  the  nature  and  morphology  of  the  interstitial  cells. 

Equally  interesting  have  been  the  speculations  regarding  the  origin  of  these 
cells.  Schroen  in  1863  regarded  them  as  fragments  of  disintegrating  corpora 
lutea.  His  and  Waldeyer  considered  them  wandering  cells.  Tourneaux 
recognized  the  homology  between  them  and  the  cells  of  Leydig,  and  ascribed 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  49 

their  origin  to  the  pre-existing  connective  tissue,  a  theory  which  we  shall  see 
harmonizes  with  views  of  the  present  time.  Schuhn  described  them  as  epithelial 
structures;  Harz,  as  offshoots  of  the  glomeruli  of  the  kidney;  Chiarugi  saw  in 
them  rests  of  the  Wolffian  body. 

Limon  was  the  first  to  recognize  their  origin  from  the  lutein  cells  of  the  theca 
interna  of  the  atretic  folHcles.  Limon's  views  have  been  adopted  by  the  best 
investigators,  and  it  is  now  generally  accepted  that  the  interstitial  cells  of  the 
ovary  either  are  identical  with  the  lutein  cells  of  the  atretic  follicles  or  at  least  are 
derived  from  them  (TancUer  and  Gross) .  The  inconstancy  of  the  appearance  of 
"the  interstitial  cells  is  explained  by  the  fact  that  in  some  species  or  under  certain 
conditions  during  the  process  of  follicle  atresia  the  theca  lutein  cells  become 
"disaggregated,"  that  is  to  say,  separated  from  the  surrounding  envelope  of  the 
follicle  (theca  externa)  and  deposited  in  gland-like  masses,  or  scattered  indis- 
criminately through  the  ovarian  stroma.  Thus,  in  the  rabbit,  disaggregation 
takes  place  and  the  theca  lutein  cells  are  found  in  gland-like  masses  to  which  the 
term  "interstitial  gland"  has  been  given. ^  In  the  human  ovary,  on  the  other 
hand,  disaggregation  takes  place  only  rarely,  and  the  theca  lutein  cells  remain 
confined  by  the  external  envelope  of  the  follicle.  Hence  an  interstitial  gland  is 
not  seen  in  the  human  ovary.  It  is  quite  conceivable  that  the  function  of  the 
interstitial  cells  as  producers  of  an  internal  secretion  might  be  performed  equally 
well  whether  limited  by  a  theca  externa  or  scattered  in  the  stroma. 

If  we  accept  the  theory  of  the  identity  of  the  interstitial  cells  and  the  follicle 
lutein  cells,  we  must  conclude  that  the  production  of  the  interstitial  cells  is,  in 
reality,  a  function  of  folHcle  atresia. 

If,  now,  it  can  be  shown  by  animal  experimentation  and  otherwise  that  the 
interstitial  cells  are  producers  of  an  internal  secretion,  then  we  must  conclude 
that  follicle  atresia  is  not  a  pathologic  but  a  physiologic  process,  the  object  of 
which  is  the  elaboration  of  an  internal  secretion. 

The  detailed  proof  of  the  internal  secretory  power  of  the  interstitial  cells 
cannot  be  included  in  the  scope  of  this  section.  We  can  only  allude  to  the  in- 
fluence of  the  ovary  on  the  growth  of  the  individual  before  puberty  as  shown  by 
early  castration;  to  the  experiments  with  roentgenization,  showing  the  influence 
of  the  interstitial  cells  on  secondary  sexual  characteristics;  to  the  homology  of  the 
interstitial  ceUs  and  the  cells  of  Leydig,  and  to  the  effects  of  ovarian  transplanta- 
tion and  ovarian  therapy,  in  which  the  influence  of  the  corpus  luteum  is  excluded. 

Thus  we  have  sufficiently  convincing  evidence  that  the  internal  secretion  of 

^  The  interstitial  gland  is  most  pronounced  in  rodents,  insectivora,  chiroptera,  and  animals  of 
prey.  It  is  most  apparent  in  early  youth.  With  the  appearance  of  the  first  corpus  luteum  the  inter- 
stitial gland  decreases,  so  that  there  seems  to  be  a  certain  reciprocity  between  the  corpus  luteum 
and  interstitial  gland,  which,  as  stated  above,  is  derived  from  the  theca  interna  cells  of  the  atretic 
follicle.  Good  development  of  the  interstitial  gland  in  these  animals  is  apparently  associated  with 
good  fertility. 

In  animals  that  bear  many  young  at  the  same  time  the  interstitial  gland  is  found  highly  organ- 
ized at  the  age  of  sexual  maturity,  whereas  in  animals,  like  man,  monkeys,  and  the  hoofed  animals, 
the  gland  is  found  poorly  developed.  In  the  latter  case  the  gland  is  rudimentary  at  its  best,  and  dis- 
appears completely  after  the  appearance  of  the  first  corpus  luteum  (Aschner). 


50  GYNECOLOGY 

the  ovary  is  manufactured  both  by  the  corpus  luteum  and  by  the  atretic  folKcles. 
It  is  now  necessary  to  point  out  the  relationship  between  these  two  mechanisms 
from  a  physiologic  standpoint.  The  exact  nature  of  the  lutein  cells  of  the  corpus 
luteum  has  been  a  matter  of  much  discussion.  Some  have  regarded  them  as 
epithelial  in  origin,  others  as  derivatives  of  connective  tissue.  According  to 
Pfannenstiel,  the  lutein  cells  are  partly  epithehal  and  partly  connective  tissue 
in  structure.  By  this  theory  the  innermost  layers  of  cells  toward  the  center  of 
the  corpus  luteum  represent  a  luteal  reaction  of  the  granulosa  cells  which  develop 
from  the  original  epithehal  hning  of  the  Graafian  follicle;  wliile  the  outer  or 
theca  layers  represent  a  like  reaction  of  prohferating  cells  springing  from  the 
connective-tissue  envelope,  or  theca  interna.  These  last  named  elements  of  the 
corpus  luteum  were  termed  by  Pfannenstiel  ''theca  lutein"  cells.  They  corre- 
spond in  the  matured  corpus  luteum  to  the  lutein,  or  interstitial  cells  of  the  atretic 
follicle. 

The  function  of  the  theca  lutein  cells  is  probably  twofold.  The  presence  of 
fat  in  the  protoplasm  and  the  rich  network  of  blood-vessels  with  which  they  are 
invested  early  suggested  that  they  supply  nutritive  material  for  the  development 
of  the  egg.  The  theory  that  they  elaborate  an  internal  secretion  is  of  compara- 
tively recent  date.  To  them  was  first  ascribed  hypothetically  a  specific  in- 
fluence on  the  sexual  impulse  and  the  development  of  the  secondary  sexual 
characters,  the  latter  theory  being  now  well  estabhshed  by  experimental  proof. 

Between  the  corpus  luteum  and  the  interstitial  gland  {i.  e.,  disaggregated  interstitial  cells 
in  gland-like  mass)  an  interesting  reciprocal  relationship  has  been  pointed  out  by  Bouin  and 
Ancel,  who  have  divided  animals  into  two  groups  according  to  their  methods  of  ovulation. 
To  the  first  group  belong  those  species  in  which  ovulation  occurs  only  after  coitus,  as  in  the 
rabbit,  guinea-pig,  mouse,  and  cat.  Representatives  of  the  first  group  exhibit  a  periodic  corpus 
luteum  and  a  corpus  luteum  of  pregnancy,  but  not  a  well-defined  interstitial  gland;  while  those 
of  the  second  group  have  a  corpus  luteum  of  pregnancy,  but  in  place  of  a  periodic  corpus  luteum 
an  interstitial  gland  (Tandler  and  Gross). 

It  has  been  objected  that  the  interstitial  cells,  being  of  connective-tissue  origin, 
are  not  of  the  true  endosecretory  type,  which  is  usually  epithehal  in  character. 
This  objection  is  met  by  the  fact  that  certain  other  connective-tissue  elements 
are  known  to  possess  endosecretory  power,  notably  the  suprarenal  cortex 
and  the  cehs  of  Leydig.  It  has  been  demonstrated  that  the  endosecretory 
elements  exhibit  characteristic  staining  properties,  and  among  these  elements 
has  been  included  a  list  of  cehs  of  connective-tissue  origin,  such  as  the  cells  of 
the  serosa,  the  stellate  cells  of  the  liver,  the  reticulum  of  the  blood  and  lymph 
apparatus,  and  the  bone-marrow  (Goldmann). 

Another  point  of  interest  is  the  manner  of  growth  of  the  interstitial  cells. 
It  is  quite  evident  that  they  develop  from  the  pre-existing  connective-tissue 
cells  of  the  ovarian  stroma,  which  at  a  given  moment  "become  activated"  and 
take  on  the  morphologic  character  and  functional  properties  of  interstitial  cells 
(Tandler  and  Gross).     It  is  conceivable,  therefore,  that  the  undifferentiated 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM        51 

stroma  cells  of  the  ovary  have  endosecretory  powers  which  may  be  of  value  in 
the  manufacture  of  ovarian  extracts  for  therapeutic  purposes. 

An  important  phase  in  the  study  of  the-  ovarian  internal  secretion  is  the  ques- 
tion of  the  selective  action  of  certain  of  the  secretory  elements.  This  part  of  the 
subject  is  at  present  very  much  in  the  dark.  Fraenkel's  assertion  that  the  corpus 
luteum  regulates  the  nidation  and  early  growth  of  the  egg  is  by  no  means  uni- 
versally accepted.  The  early  theory  that  the  corpus  luteum  presides  over 
menstruation  is  no  longer  tenable,  some  even  holding  that  menstruation  is  deter- 
mined by  the  elimination  of  the  corpus  luteum.  Loeb's  view  that  the  corpus 
luteum  inhibits  ovulation  and  that  it  is  responsible  for  the  growth  of  the  maternal 
placenta  is  well  established.  Quite  definite  is  the  evidence  that  the  interstitial 
gland  presides  over  the  development  of  the  secondary  sex  development,  experi- 
ments having  shown  that  the  sex  characters  remain  if  the  purely  generative 
portions  of  the  ovaries  are  excluded  by  the  Roentgen  ray,  whereas  these  charac- 
ters undergo  wide  variation  after  early  castration  (Tandler  and  Gross).  There 
is  much  to  show,  on  the  other  hand,  that  the  action  of  the  ovarian  secretion  is 
neither  direct  nor  selective,  but  that  it  exerts  only  a  balancing  influence  on  other 
correlated  and  more  powerful  glands,  the  activity  of  which  the  ovarian  secretion 
discharges  or  suppresses,  as  the  case  may  be. 

Clinical  manifestations  of  disturbances  of  the  glands  of  internal  secretion 
are  caused  either  by  deficient  activity  (hypofunctioii)  or  by  an  abnormal  in- 
crease of  activity  (hyperfunction)  of  the  glandular  secreting  substance.  Under 
hypofunction  must  be  considered  not  only  the  effects  of  diminished  secretory 
power,  but  also  the  results  of  complete  destruction  or  extirpation  of  the  organ. 
In  studying  the  effects  of  the  removal  or  destruction  of  a  given  ductless  gland 
one  must  take  into  account  not  only  the  influence  of  the  loss  of  its  specific  secre- 
tion on  the  organism,  but  also  the  changes  wrought  in  the  other  members  of 
the  group,  the  balance  of  whose  function  has  thus  been  disturbed. 

Hypofunction  of  the  Ovary. — Castration  Before  Maturity.— We  have  seen 

that  early  castration  prevents  normal  development  of  the  genital  system.     It 

also  produces  changes  in  some  of  the  other  ductless  glands,  the  most  notable 

being  that  of  the  hypophysis,  in  which  there  takes  place  an  increase  in  the  size 

.  of  the  anterior  lobe. 

It  is  generally  though  not  universally  conceded  that  this  hypertrophy  of  the 
hypophysis  is  the  cause  of  the  skeletal  deviations  and  accumulation  of  fat  that 
characterize  the  individual  of  the  eunuchoid  type. 

Nearly  all  generalizations  on  this  subject  have  been  from  observations  of 
castrated  males.  In  human  beings  information  on  this  subject  is  gained  chiefly 
from  a  study  of  the  eunuchs  of  the  Turkish  harems  and  from  a  religious  sect  in 
Russia  called  the  Skopts.  It  may  be  said  that  the  body  length  of  individuals 
who  have  been  castrated  early  in  general  exceeds  that  of  the  non-castrated, 
an  observation  which  is  familiar  in  animals  also,  as  in  the  case  of  oxen,  geldings, 
and  capons.     Tandler  and  Gross  and  others  ascribe  this  fact  to  a  delayed  ossifica- 


52  GYNECOLOGY 

tion  of  the  epiphyseal  joints,  which  produces  not  only  an  increase  in  growth,  but 
a  deviation  from  the  normal  body  proportions.  The  result  is  that  the  individual 
produced  by  early  castration  is  not,  in  general,  of  the  infantile  type,  but,  on  the 
contrary,  far  removed  from  it.  While  we  find  in  children  a  relatively  long 
trunk  and  short  extremities,  and  a  proportionately  large  skull,  with  small  face, 
we  find  in  the  castrated  a  marked  increase  in  the  length  of  the  extremities  and  a 
skull  relatively  small  in  comparison  with  the  face.  These  gross  physical  changes 
are  constantly  observed  both  in  man  and  in  animals,  and  it  is  not  surprising, 
therefore,  to  find  that  there  also  usually  exists  an  enlargement  of  the  sella  turcica 
due  to  hypertrophy  of  the  hypophysis.  It  is,  therefore,  seen  that  the  genital 
glands  may  bear  an  antagonistic  relationship  to  the  hypophysis,  and  that  the 
early  removal  of  the  inhibitory  influence  of  the  testis  or  ovary,  allows  for  an 
overdevelopment  of  the  hypophysis  with  corresponding  skeletal  changes  (Novak). 

Another  characteristic  of  the  eunuch  possibly  referable  to  the  increase  of 
the  hypophysis  is  the  accumulation  of  adipose  tissue  which  is  usually  though 
not  always  present.  The  muscles  become  permeated  with  fat.  The  distribution 
of  fat  over  the  body  corresponds  to  that  of  the  condition  of  dystro'phia  adiposo- 
genitalis,  i.  e.,  in  the  hypogastric  region,  on  the  mons  veneris,  on  the  nates,  hips 
and  thighs,  and  on  the  mammary  glands.  There  is  also  a  characteristic  deposit 
on  the  upper  eyelids  which  may  cause  them  to  hang  down  like  bags.  There  is  a 
deficiency  in  the  growth  of  hair. 

The  distribution  of  fat,  especially  over  the  hips  and  nates  of  the  male  castrate, 
produces  a  suggestively  feminine  appearance,  which  taken  together  with  the 
absence  of  hair  and  the  persistence  of  a  high-pitched  voice  has  led  to  the  general 
belief  that  castration  imparts  to  the  individual  characteristics  of  the  opposite 
sex.  This  is  emphatically  not  the  case.  The  deposition  of  fat  and  the  meager 
growth  of  hair  are  purely  the  result  of  internal  secretory  reaction.  The  high- 
pitched  voice  is  not  caused  by  a  larynx  of  female  type.  The  organ  resembles 
rather  that  of  a  child,  in  that  there  is  no  prominentia  laryngea  and  ossification  has 
not  taken  place.  "For  this  reason  the  voice  retains  its  childish  character  and  in 
no  way  resembles  a  woman's  voice;  it  is  a  childish  soprano  which  late  in  life 
undergoes  the  changes  in  timbre  and  tone  characteristic  of  mutation"  (Biedl). 
Apart  from  the  high  voice,  deficient  hair,  and  the  general  deposition  of  fat  the 
eunuch  does  not  approach  the  feminine  type.  The  character  of  men  castrated 
early  in  life  has  been  variously  estimated.  They  are  said,  in  general,  to  be  de- 
ficient in  the  courage,  passions,  and  aspirations  of  normal  men,  but  there  is  no 
diminution  in  intellectual  capabilities.  Some  eunuchs  have  attained  high 
positions.  Temperamentally  the  castrated  man  is  quiet  and  phlegmatic,  a 
characteristic  that  could  hardly  be  generally  ascribed  to  woman. 

It  is  important  to  emphasize  the  fact  that  early  castration  does  not  trans- 
form the  individual  into  the  heterosexual  type,  for  it  has  a  twofold  significance. 
Not  only  does  it  have  an  important  bearing  on  the  subject  of  sex  determination 
(q.  v.),  but  it  contradicts  certain  popular  conceptions  as  to  the  after-results  of 
late  castration — a  matter  of  considerable  moment  to  the  gynecologist. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM        53 

Information  regarding  the  results  of  castration  before  puberty  in  women  is 
exceedingly  meager.  From  the  few  observations  made  in  the  human  race  and 
from  animal  experimentation  it  may  be  assumed  that  early  castration  in  women  is 
followed  by  lack  of  development  of  secondary  sexual  characters  including  the 
breasts,  and  that  the  skeletal  changes  resemble  those  of  the  male  castrate. 

Castration  After  Maturity. — Whereas  the  effects  of  castration  before  puberty 
have  been  studied  chiefly  in  men,  the  opportunity  for  observing  the  results  of 
late  castration  is  best  afforded  in  women,  in  whom  the  operation  for  removal  of 
the  internal  genital  organs  is  frequently  required. 

From  a  physiologico-chemical  standpoint  the  influence  of  castration  after 
maturity  has  been  extensively  studied,  but  at  the  present  time  no  very  important 
results  have  been  gained.  Schickele  has  observed  an  increase  in  the  arterial 
tension  at  the  natural  menopause  and  regards  the  effect  as  due  to  the  loss  of  the 
depressor  influence  of  the  ovarian  secretion.  His  observations  have  not  been 
confirmed. 

Variations  in  sugar  assimilation,  coagulation  time  of  the  blood,  blood-picture, 
chemical  composition  of  the  blood,  reaction  to  drugs,  etc.,  have  been  described, 
but  cannot  be  detailed  here,  as  in  our  present  state  of  knowledge  they  are  of 
minor  importance  to  the  practical  gynecologist.  It  is  probable  that  many  of 
these  changes  are  the  result  of  disturbing  the  balance  of  the  other  ductless  glands, 
and  that  the  abnormalities  are  produced  by  the  internal  secretion  of  organs  whose 
influence  on  the  general  metabolism  is  more  powerful  than  that  of  the  ovary. 

From  clinical  observations  it  may  be  said  that  late  castration  in  women 
has  comparatively  little  effect  and  that  it  does  not  entail  the  profound  mental 
and  physical  change  in  the  organism  of  the  individual  that  was  formerly  supposed. 
Concerning  this  subject  much  will  be  said  throughout  this  vv'ork  (see  especially 
section  on  Neurology) .  One  of  the  popular  misconceptions  regarding  the  results 
of  oophorectomy  is  that  certain  features  of  the  male  type  may  be  acquired,  such 
as  a  deepening  of  the  voice,  increase  of  facial  hair,  coarsening  of  the  skin,  and  a 
general  assumption  of  the  masculine  character.  Such  ideas  have  doubtless  been 
derived  by  reasoning  from  a  reverse  analogy  to  eunuchs.  It  has  been  pointed 
out  above  that  even  after  castration  before  maturity  there  is  not  the  slightest 
evidence  of  a  transformation  to  the  type  of  the  opposite  sex.  This  is  seen  not 
only  in  human  beings,  but  in  animals,  and  it  may  be  definitely  stated  that  after 
early  castration  the  males  of  no  species  become  feminine  in  type,  nor  do  the 
females  become  masculine.  If  this  fact  is  true  after  early  castration  it  must 
certainly  hold  good  after  late  castration  when  the  organism  has  been  permanently 
established  both  constitutionally  and  by  habit. 

Another  exaggerated  idea  regarding  late  castration  relates  to  the  accumula- 
tion of  fat.  There  is  no  doubt  that  there  exists  a  certain  relationship  between 
adiposity  and  genital  deficiency.  This  is  seen  in  the  results  of  early  castration 
and  in  certain  internal  glandular  diseases  which  are  attended  with  lack  of 
development  or  atrophy  of  the  reproductive  organs.     In  some  instances  where 


54  GYNECOLOGY 

functional  amenorrhea  appears  in  a  previously  normal  woman  there  ensues  an 
abnormal  accumulation  of  fat,  though  in  these  cases  there  is  usually  a  pluri- 
^  glandular  involvement.  A  noticeably  large  percentage  of  sterile  women  are  fat. 
Much  is  said  of  the  increase  of  fat  in  women  who  have  reached  the  menopause, 
but  this  statement  has  undoubtedly  been  much  exaggerated.  Women  who  are 
destined  to  become  fat  usually  begin  to  increase  in  weight  long  before  the  meno- 
pause, and  often  reach  theu'  maximum  before  menstruation  ceases.  Often  the 
increase  after  the  menopause  is  only  apparent,  for  at  that  time  the  external 
tissues  lose  their  firm  contour  and  the  fat  settles  into  irregular  and  baggy  folds, 
giving  the  impression  of  increase  in  size,  though  there  may  be  no  increase  ui 
weight. 

In  like  manner  the  increase  of  fat  after  removal  of  the  ovaries  in  adult  women 

has  been  very  greatly  overstated,  as  any  experienced  gynecologic  surgeon  will 

testify.     As  a  result  of  our  personal  experience  we  are  able  confidently  to  assert 

that  castration  of  matured  women  is  not  ordinarily  followed  by  a  greater  tendency 

X     to  adiposity  than  is  any  other  operation,  though  it  may  happen  in  rare  cases. 

The  abnormal  accumulation  of  fat  that  follow^s  early  castration  is  undoubtedly 

due  to  resultant  changes  in  some  other  part  of  the  internal  glandular  system, 

. .  probably  in  the  hypophj^sis.     When  castration  takes  place  during  full  matmity 

the  other  glands  of  internal  secretion  are  little  affected,  so  that  symptoms  of  dis- 

_•  turbance  are  usually  slight  and  transitory  and  often  do  not  occur  at  all. 

A  similar  difference  between  earty  and  late  castration  is  seen  in  the  matter 
of  the  sexual  impulse.  In  males  who  have  been  castrated  before  puberty  sexual 
'  instinct  is  absent.  When  castration  is  performed  after  maturitj'  libido  is  re- 
tained for  a  long  time  and  copulation  is  possible,  with  ejaculation  of  the  prostatic 
fluid. 

In  females  early  removal  of  the  ovaries  would  undoubtedly  be  followed  by 
complete  absence  of  the  sexual  instinct.  After  oophorectomy  in  matured  women 
who  have  experienced  intercourse  and  in  whom  the  hbido  has  been  normally 
awakened  the  sexual  impulse  in  the  majorty  of  cases  is  retained  for  a  number  of 
years,  though  its  duration  is  probably  not  as  long  as  in  normal  women.  It  is 
not  infrequently  noted  that  late  castration  may  produce  for  a  time  at  least  an 
actual  increase  of  the  libido.  In  our  own  record  of  cases  a  number  of  women 
have  reported  that  the  sexual  impulse  became  somewhat  less  constant,  but,  on 
the  other  hand,  more  spasmodic  and  intense. 

In  the  section  on  the  relation  of  gynecology  to  sex  it  will  be  seen  that  in  many 
normal  women  the  libido  is  not  awakened  before  sexual  experience  occurs,  and 
J  then  only  gradually.  It  would  be  interesting  and  in  many  instances  important 
to  know  if  after  the  castration  of  a  matured  woman  this  awakening  of  the  sexual 
impulse  would  take  place  as  under  normal  conditions.  So  far  as  we  can  discover 
no  observations  on  this  point  have  been  recorded. 

From  the  foregoing  the  conclusion  must  be  drawn  that  the  sexual  impulse 
after  maturity  is  by  no  means  exclusively  dependent  on  the  presence  of  the  genital 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM        55 

glands.  This  dependence  must  be  sought  undoubtedly  in  the  influence  of  other 
glands  of  internal  secretion,  a  subject  of  the  deepest  significance  which  has  not 
yet  been  elaborated.  It  has  already  been  suggested  (Gushing,  Falta,  and  others) 
that  the  Freudian  theory,  which  postulates  an  enormous  influence  of  the  libido 
in  subconscious  human  motivation,  may  be  explained  on  the  basis  of  the  internal 
secretions.  It  is  entirely  probable  that  many  if  not  all  the  endocrine  glands,  in 
addition  to  their  other  physiologic  properties,  possess  dii-ectly  or  indirectly 
sex-impelhng  attributes. 

The  most  definite  results  of  late  castration  in  women  are  manifested  by 
atrophy  of  the  genital  system  and  by  certain  temporary  vasomotor  disturbances. 
The  subject  of  postoperative  atrophy  is  mentioned  below,  and  is  again  fully  dis- 
cussed in  the  special  section  on  Genital  Atrophy  {q.  v.).  The  subject  of  the  vaso- 
motor symptoms  following  oophorectomy  is  elaborated  in  the  section  on  the 
Relationship  of  Gynecology  to  Neurology. 

Infantilism. — The  relationship  between  early  hypofunction  of  the  ovaries 
and  hypoplasia  or  infantilism  is  a  subject  about  which  there  is  much  doubt. 
It  is  probable  that  most  cases  of  infantilism  are  the  result  of  some  other  cause 
than  primary  ovarian  deficiency.     (See  also  section  on  Infantilism  and  Sterility.) 

Infantilism  relates  to  arrested  development  of  various  parts  of  the  body,  and  may  manifest 
itself  universally  in  all  parts  of  the  body  (infantilismus  universalis)  or  it  may  appear  only 
locally  (infantilismus  partiaUs).  The  manifestations  of  the  condition  in  which  we  are  par- 
ticularly interested  are  those  that  are  seen  in  connection  with  the  abdominal  and  pelvic  organs 
and  with  the  external  female  genitals,  for  some  of  them  are  of  great  clinical  importance  to  the 
surgeon.  Some  of  the  familiar  stigmata  of  the  infantile  or  hypoplastic  condition  in  the  abdo- 
men are  enteroptosis,  abnormal  mobihty  of  cecum  and  sigmoid,  prolapse  of  the  kidney,  pelvic  , 
kidney,  short  appendiculo-ovarian  hgament,  funnel-shaped  appendix,  etc.  In  the  pelvis  there 
are  the  congenital  or  developmental  uterine  malpositions  of  retroflexion,  acute  anteflexion,  ante- 
flexion with  retrocession,  and  procidentia,  all  of  which  may  cause  chnical  symptoms.  In 
addition  to  this  are  the  anomahes  due  to  the  failure  of  complete  union  of  the  Miillerian  ducts, 
causing  the  various  forms  of  uterus  didelphys  and  atresia,  some  of  which  may  result  in  serious 
surgical  comphcations.  It  was  formerly  supposed  that  these  manifestations  of  infantilism  were 
due  to  a  deficient  development  of  the  ovary  from  the  fact  that  the  ovary  is  sometimes  found 
hjq^oplastic.  The  present  theory  is  that  the  local  stigmata  of  infantilism,  such  as  are  seen  in 
the  genitalia,  are  merely  manifestations  of  a  general  "hypoplastic  constitution,"  and  that  hypo- 
plasia of  the  ovary,  when  it  occurs,  is  only  an  incident  and  not  a  cause  of  the  general  condition. 
In  the  great  majority  of  these  cases  the  uterus  is  distinctly  infantile,  but  the  ovaries  are  either 
normal  or  actually  larger  than  normal  (excluding  the  occm'rence  of  cystic  degeneration  or 
thickened  albuginea) . 

It  is  sufficiently  evident,  therefore,  that  infantilism  is  not  necessarily  due  to  ovarian 
deficiency.  On  the  other  hand,  full  development  of  the  secondary  characters  may  occur  even 
in  the  complete  absence  of  the  ovaries.  This  is  most  commonly  observed  in  cases  of  deficient 
union  of  the  Miillerian  ducts  in  which,  according  to  Burrage,  the  ovaries  are  completely  absent 
in  18  per  cent. 

In  cases  of  absence  of  the  vagina  the  ovaries  are  sometimes  either  absent  or  only  rudimentary. 
Many  of  these  women  are  in  every  other  way  fully  developed  sexually  and  are  sought  in  mar- 
riage; hence,  the  not  infrequent  necessity  of  the  operation  for  making  an  artificial  vagina. 

Atrophy. — Although  up  to  the  time  of  puberty  the  ovaries  seem  to  have 
but  moderate  local  or  constitutional  effect,  we  find  definite  evidence  to  show 


J 


56  GYNECOLOGY 

that  during  the  child-bearing  and  menstrual  period  of  life  the  ovaries  not  only- 
exercise  a  distinct  trophic  influence  over  the  uterus  and  external  genitals,  but 
they  seem  to  play  a  certain  more  or  less  important  part  in  the  general  chem- 
istry of  the  organism.  This  is  best  seen  in  the  atrophy  of  the  uterus  and  ex- 
ternal genitals,  which  takes  place  when  the  ovaries  become  atrophied  or  are 
removed  after  attaining  the  period  of  full  maturity.  When  atrophy  of  the 
ovary  takes  place  the  organ  becomes  shrunken  in  size,  the  follicles  cease  to 
ripen,  and  degenerative  changes  appear  in  the  follicle  apparatus.  The  condi- 
tion when  complete  is  manifested  by  amenorrhea.  The  uterus  becomes  small 
and  flaccid,  the  cervix  is  shrunken  and  flattened.  The  labia  become  less  full 
and  rounded,  the  minora  are  slender  and  less  prominent,  and,  flnally,  disappear 
entirely.  The  vaginal  and  vulvar  mucous  membrane  is  pale,  inelastic,  and 
contracted,  and  may  give  rise  to  most  distressing  symptoms.  Physiologically, 
ovarian  deficiency  appears  at  the  menopause  and  during  lactation. 

According  to  Thorn,  lactation-atrophy  of  the  ovaries  with  secondary  atrophy 
of  the  uterus  is  a  constant  phenomenon  in  nursing  women.  Frankel  describes 
it  as  appearing  during  the  third  month  after  childbirth,  and  as  disappearing 
in  the  seventh  month  even  if  the  mother  continues  to  nurse.  Foges  has  shown 
that  this  atrophy  is  due  to  a  cessation  of  the  function  of  the  ovaries  and  not  to 
the  nursing  of  the  mother. 

Pathologic  ovarian  cleficiencj^,  as  indicated  by  secondary  atrophj-  of  the 
other  genitals,  is  said  to  follow  local  pelvic  conditions  of  inflammation  and 
tumor  formation,  but  this  is  rare,  for  in  most  cases  the  ovarian  tissue  con- 
tinues to  functionate  even  though  only  a  very  small  portion  is  left  by  the  dis- 
ease. Ovarian  atrophy  sometimes  follows  infectious  and  constitutional  dis- 
eases, such  as  scarlet  fever,  articular  rheumatism,  diseases  of  the  thjToid, 
anemias,  paralyses,  etc.     (See  section  on  Genital  Atrophy.) 

Fimctional  Amenorrhea. — The  amenorrhea,  or  oligomenorrhea,  that  is 
seen  in  fully  developed  women,  who  have  previously  menstruated  normally, 
is  accounted  for  as  a  result  of  functional  ovarian  deficiencj^,  a  theory  that 
finds  strong  confirmation  in  the  almost  immediate  beneficial  effect  which 
ovarian  extract  usually  has  on  these  cases. 

Burnam  describes  an  ovarian  deficiency  which  manifests  itself  in  women 
of  the  fourth  decade  of  life  by  lassitude,  depression,  and  general  ineffectiveness, 
a  condition  which  he  has  been  able  greatly  to  benefit  by  the  adixdnistration 
of  large  doses  of  corpus  luteum  extract. 

How  far  sterihty  and  dysmenorrhea  are  caused  by  hj-pofunction  of  the 
ovaries  has  not  been  determined.  Ovarian  extract  occasionally  influences  these 
conditions,  as  shown  b}"  the  most  recent  observations  of  the  author. 

Hyperfunction  of  the  Ovary. — Our  present  knowledge  of  the  influence  of 
hypersecretion  of  the  ovary  is  very  theoretic  and  not  sufficiently  well  founded 
on  scientific  facts.  Abnormal  activity  of  the  gland  is  supposed  to  be  mani- 
fested by  menorrhagias  and  possibly  by  premature  sexual  development  and 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       57 

overfertility.  From  a  clinical  standpoint,  the  most  important  phase  of  the 
question  is  that  which  applies  to  those  cases  of  uterine  bleeding  which  cannot 
be  satisfactorily  explained  on  an  anatomic  basis.  This  includes  cases  even 
when  certain  demonstrable  anatomic  changes  are  associated  with  the  bleed- 
ing, such  as  myomata,  chronic  endometritis,  glandular  hypertrophy,  chronic 
metritis  (increase  of  connective  tissue),  chronic  oophoritis,  small  cystic  de- 
generation of  the  ovaries,  etc.^ 

It  also  includes  those  baffling  cases  of  so-called  uterine  insufficiency  in 
which  there  is  severe  menorrhagia  without  macroscopic  or  microscopic  change 
in  the  tissues  of  uterus  or  adnexa. 

1  Schickele  and  Keller,  in  an  article  (Arch.  f.  Gyn.,  1912,  Bd.  95,  Heft  .3)  entitled  "On  So-called 
Chronic  Metritis  and  Small  Cystic  Degeneration  of  the  Ovaries;  Their  Relation  to  Uterine  Bleeding," 
have  supplemented  their  work  on  the  relationship  of  the  glandular  changes  of  the  endometrium  to 
uterine  bleeding.  These  investigators  undertook  to  verify  the  theory  of  Theilhaber  that  the  bleeding 
from  cases  of  uterine  insufficiency  is  due  to  an  abnormal  disproportion  between  the  connective  tissue 
and  muscle-fibers  of  the  uterine  wall.  In  a  verj^  laborious  piece  of  work  they  took  sections  from  the 
myometrium  of  a  considerable  number  of  extirpated  uteri.  The  sections  were  stained  by  the  Van 
Gieson  method  and  projected  on  millimeter  paper,  on  which  drawings  were  made  of  the  connective 
tissue.  In  this  way  a  fairly  accurate  calculation  was  made  of  the  amount  of  connective  tissue  rela- 
tive to  the  muscular  fibers.  Their  calculations  led  them  to  conclude  that  uterine  hemorrhages  had 
nothing  to  do  with  the  amount  of  connective  tissue  in  the  myometrium.  Hemorrhages  may  occur 
with  an  associated  hypertrophy  of  the  connective  tissue,  or  they  may  occur  -with,  a  perfectly  normal 
amount  of  connective  tissue.  On  the  other  hand,  abnormal  bleeding  may  be  entirely  absent  in 
association  vnth  great  overgrowth  of  the  connective  tissue. 

The  same  two  investigators  studied  the  ovaries  of  7  cases  of  uterine  insufficiency  in  which  the 
uterus  and  adnexa  had  been  extirpated,  and  found  no  characteristic  anatomic  changes  in  the  follicles, 
connective  tissue,  blood-vessels,  or  albuginea,  to  which  abnormal  uterine  bleeding  could  be  assigned 
as  a  cause. 

The  careful  studies  of  Schickele  and  Keller  of  the  relationship  between  endometrium,  myome- 
trium, and  ovaries,  with  abnormal  uterine  bleeding,  are  worthy  of  especial  attention.  Their  general 
conclusions  may  be  summed  up  as  follows: 

The  idea  that  bleeding  and  leukorrhea  are  cardinal  symptoms  of  so-called  endometritis  (gland 
hj'pertrophy)  must  in  the  future  be  modified.  It  is  well  established  that  severe  hemorrhages  may 
take  place  both  during  and  outside  of  menstruation  without  the  slightest  change  in  the  endometrial 
glands;  on  the  other  hand,  marked  conditions  of  gland  hyperplasia  may  exist  without  any  abnormal 
bleeding.  There  can,  therefore,  be  no  essential  connection  between  abnormal  uterine  bleeding  and 
changes  in  the  endometrial  glands.  Although  uterine  bleeding  and  gland  hyperplasia  may  exist  at 
the  same  time,  there  is  no  reason  for  declaring  that  the  bleeding  is  caused  bj'  the  glandular  condition. 
There  is  no  anatomic  characteristic  change  in  the  mucous  membrane,  which,  as  such,  calls  forth 
hemorrhage  or  leukorrhea. 

The  same  thing  may  be  said  with  regard  to  so-called  chronic  metritis  (increase  of  connective 
tissue).  There  is,  as  a  matter  of  fact,  a  true  metritis,  which  depends  for  its  origin  on  bacterial  infec- 
tion, and  which  on  healing  develops  certain  anatomic  changes,  but  we  have  no  proof  how  often  this 
form  occurs,  what  its  anatomic  characteristics  are,  and  whether  there  exists  any  connection  between 
it  and  uterine  bleeding.  Hyperplasia  of  the  connective  tissue  cannot  be  looked  on  as  an  expression 
of  such  a  chronic  metritis  any  more  than  can  the  dilatation  of  the  blood-vessels,  which  is  also  present. 

It  is  certain  that  a  hj-perplasia  of  the  uterine  connective  tissue  does  not  necessarily  produce 
abnormal  bleeding.  If  there  were  any  such  connection  between  the  two,  we  should  have  abnormal 
bleeding  with  every  case  of  connective-tissue  hyperplasia,  and  the  greater  the  hyperplasia,  the  more 
intense  would  be  the  bleeding.  This  is  not  the  case.  Those  cases  in  which,  in  spite  of  a  normal 
amount  of  connective  tissue,  and,  therefore,  well-developed  musculature,  intense  hemorrhages  occur, 
make  it  still  clearer  that  the  real  etiologic  factor  is  something  different  and  more  important. 

Everything  forces  us  to  the  conclusion  that  the  causes  of  abnormal  uterine  bleeding  must  be 
sought  elsewhere  than  in  the  anatomic  changes  of  the  uterus.  We  naturally  turn  next  to  the  ovary 
as  the  organ  which  would  be  most  likely  to  influence  the  uterus.  In  the  ovary  anatomic  changes  can 
be  demonstrated  which  may  occur  simultaneouslj^  with  atypic  uterine  bleeding.  However,  it  is  an 
established  fact  that  these  same  atypic  bleedings  may  take  place  without  any  demonstrable  anatomic 
change  in  the  ovaries.  This  fact  leaves  the  significance  of  the  above-mentioned  changes  of  the  ovaries 
in  a  very  uncertain  light.  We  do  not  even  know  whether  the  functional  processes  in  the  ovary  express 
themselves  in  its  anatomic  structure :  whether  any  anatomic  changes  of  the  ovaries  signify  the  outer 
sign  of  functional  disturbances.  Under  such  conditions  the  reputed  significance  of  chronic  oophoritis 
or  of  small  cystic  degeneration  falls  to  the  ground.  We  have  at  present  no  clue  by  which  we  can 
judge  the  function  of  the  ovary  by  its  anatomic  appearance. 


58  GYNECOLOGY 

The  belief  that  most  uterine  bleeding  is  the  result  of  a  hypersecretion  of  the 
ovary  is  based  on  the  theory  of  interrelationship  between  ovarian  secretion  and 
menstruation,  the  course  of  reasoning  being  as  follows: 

The  functions  of  the  uterus  are  under  the  control  of  the  ovaries,  for  without  the  ovaries 
there  is  no  true  menstruation.  During  menstruation  the  blood-vessels  of  the  uterus,  and 
especially  of  the  endometrium,  are  always  dilated  and  the  normal  menstrual  blood  is  uncoagu- 
lable.  It  is  supposed,  therefore,  that  there  is  manufactured  in  the  ovaries  as  an  internal 
secretion  a  substance  which  passes  over  into  the  uterus  in  the  blood,  and  which,  when  enough  of 
it  has  accumulated,  produces  the  phenomenon  of  menstruation  by  dilating  the  capillaries  of  the 
endometrium  and  reducing  the  coagulabiUty  of  the  blood. 

The  substance  (probably  by  chemical  influence)  acts  on  the  walls  of  the  small  blood-vessels 
of  the  endometrium,  causing  a  hyaline  change  which  makes  them  more  permeable  for  the 
passage  of  the  blood.  The  menstrual  bleeding  stops  when  the  active  substance  which  causes 
dilatation  of  the  blood-vessels  and  non-coagulabihty  of  the  blood  is  eliminated  by  the  flow. 
The  ovaries  continue  to  manufacture  the  substance,  which  in  turn  continues  to  flow  over  into 
the  uterus  until  enough  is  accumulated  to  produce  again  the  menstrual  discharge.  By  this 
theory,  therefore,  abnormal  uterine  bleeding  is  easily  explained  by  the  storage  in  the  uterus  of 
an  excessive  amount  of  ovarian  secretion. 

This  theory  is  not  without  scientific  substantiation.  Of  very  great  interest  are  the  experi- 
ments of  Schickele  on  the  influence  of  uterine  and  ovarian  extracts  on  the  time  coagulability 
of  the  blood.  He  made  extracts  of  the  uterus,  endometrium,  and  ovaries  that  had  been  removed 
for  various  causes  at  surgical  operations,  and,  adding  them  to  combinations  of  animal  blood- 
serum  and  plasma,  observed  the  changes  in  the  time  of  coagulation  as  compared  with  normal 
controls.  From  these  investigations  he  proved  that  extracts  of  the  uterus  and  ovaries  delay  the 
coagulation.  In  those  cases  where  the  extracts  were  made  from  organs  in  which  abnormal 
bleeding  had  not  existed  he  found  that  the  ovarian  extract  caused  a  greater  delay  than,  did  that 
from  the  uterus.  In  those  cases  where  there  had  been  severe  menorrhagia  or  other  hemor- 
rhages, the  effect  of  the  uterine  extract  was  more  powerful  than  that  of  the  ovaries.  More- 
over, he  showed  in  these  cases  that  the  extract  from  the  endometrium  was  more  powerful  than 
that  from  the  myometrium. 

The  general  conclusion  was  that  extracts  from  organs  in  which  the  menstruation  had  been 
unduly  prolonged  caused  a  greater  delay  in  blood  coagulation  than  did  the  extracts  from  organs 
where  menstruation  had  been  normal. 

The  conclusion  from  the  foregoing  is  that  in  the  ovaries  is  produced  a  sub- 
stance that  is  passed  over  to  and  stored  in  the  uterus  and  endometrium,  which 
has  the  power  of  local  dilatation  of  the  blood-vessels  and  of  delaying  or  pre- 
venting the  coagulation  of  the  blood.  Hyperf unction  of  the  ovary  causes  an 
oversupply  of  secretion,  and  thus  brings  about  increased  or  prolonged  men- 
strual flow. 

Ovulation  and  Menstruation. — It  has  long  been  a  mooted  question  as  to 
whether  a  definite  relationship  exists  between  the  time  of  ovulation  and  men- 
struation. Observations  on  this  point  vary  considerably  in  the  study  of  the 
human  ovary  chiefly  on  account  of  the  difficulty  in  determining  the  exact  age 
of  the  corpus  luteum. 

In  order  to  facihtate  the  accumulation  of  evidence  on  this  subject  Frank  has  epitomized 
his  own  work  and  that  of  others  in  an  excellent  description  of  the  macroscopic  and  microscopic 
appearance  of  the  corpus  luteum  in  its  various  stages.  The  reader  is  referred  to  this  article 
for   the    microscopic   details   (Surgery,  G3rnecology,  and   Obstetrics,  Nov.,  1914).      In  this 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  59 

review  the  life  of  the  corpus  luteum  is  divided  into  four  stages,  the  macroscopic  appearances 
of  which  are  herewith  given  verbatim  in  order  to  aid  the  operator  who  wishes  to  make  a  series 
of  observations  of  his  own: 

(a)  Proliferative  Period. — Macroscopically,  immediately  after  ovulation  the  ruptured 
follicle  appears  as  a  small,  flaccid,  collapsed  vesicle.  This  lack  of  prominence  accounts  for  the 
fact  that  numerous  investigators  have  overlooked  the  earliest  stage.  Confusion  has  also 
arisen  from  the  gross  and  also  microscopic  resemblance  of  the  atretic  follicles  to  early  corpora 
lutea. 

(b)  Vascularization. — Macroscopically,  the  corpus  luteum  appears  as  a  typical  bluish-red 
prominence  on  the  surface  of  the  ovary.  It  is  indistinguishable  from  the  later  stages.  On 
cross-section  more  often  than  at  a  later  period  the  central  coagulum  is  fluid  or  jelly-like  in 
consistence  and  its  center  may  be  freed  from  blood,  but  no  absolute  diagnostic  value  can  be 
accorded  to  these  differences. 

(c)  Period  of  Ripeness. ^Macroscopically,  the  external  appearance  does  not  differ  from  that 
of  the  just  vascularized  corpus  luteum.  On  cross-section,  especially  toward  the  end  of  this 
stage,  the  central  coagulum  may  be  firmer,  and  a  well-defined  yellowish-brown  crenated  margin 
(the  lutein  edge)  may  surround  the  clot.  Not  infrequently  the  center  of  the  corpus  luteum  is 
cystic. 

(d)  Period  of  Regression. — Macroscopically,  the  corpus  luteum  looks  paler.  On  cross-sec- 
tion the  centrum  is  more  solid  and  colorless;  instead  of  this,  the  center  may  remain  cystic.  The 
crenated  margin  is  of  brighter  yeUow  color,  broad,  and  well  defined. 

(e)  Corpus  Luteum  of  Pregnancy. — Macroscopically,  it  is  often  larger  than  the  corpus  luteum 
of  menstruation;  but  it  cannot  be  differentiated  from  it  with  any  degree  of  certainty. 

Though  a  definite  time  relation  between  ovulation  and  menstruation  is  no 
longer  disputed,  the  exact  period  of  the  relationship  has  not  yet  been  deter- 
mined. Various  estimates  have  been  made,  but,  according  to  Frank,  we  are 
justified  in  the  present  state  of  our  knowledge  in  "concluding  merely  that  ovu- 
lation follows  menstruation  and  that  the  fertilized  ovum  (impregnation)  dates 
from  before  the  missed  period." 

There  is  evidence  to  show  that  impregnation  usually  dates  from  within  the 
first  week  following  menstruation,  and  that  the  optimum  time  for  fertilization 
is  immediately  after  the  menstrual  period. 

Meyer  and  Ruge  have  described  the  relationship  between  ovulation  and 
menstruation  as  follows: 

"In  the  28-day  cycle  of  menstruation  the  ripening  of  the  follicle  probably  comes  after 
menstruation  on  about  the  eighth  day  from  its  beginning,  if  not  during  the  time  of  menstrua- 
tion itself.  The  beginning  of  lutein  formation  is  the  second  week;  then  the  hemorrhage  fol- 
lows in  the  second  haK  of  the  third  and  in  the  fourth  week.  The  height  of  the  hemorrhage  fol- 
lows in  the  second  half  of  the  third  and  in  the  fourth  week.  The  height  of  the  hemorrhage  is 
immediately  preceding  menstruation.  During  the  latter  regression  begins  and  lasts  about 
fourteen  days.  The  normal  sequence  is  then  as  follows:  first,  the  hyperemic  stage  of  the  corpus 
luteum  during  the  interval;  the  stage  of  vascularization  of  the  corpus  luteum  at  the  beginning 
of  the  premenstrual  phase;  hemorrhage  of  the  corpus  luteum  in  the  advanced  premenstrual 
phase;  the  high  point  of  hemorrhage  of  the  mucosa  and  of  the  corpus  luteum  shortly  before 
menstruation;  and  the  regression  during  and  after  the  same.  During  pregnancy  the  corpus 
luteum  remains  at  the  high  point  of  its  hemorrhagic  state." 

The  prevailing  theory  that  there  exists  a  definite  time  relationship  between 
ovulation  and  menstruation  has  been  upset  somewhat  by  the  investigations  of 
Leopold  and  Ravano.  Their  conclusions  may  best  be  presented  in  the  following 
quotation  from  Biedl: 


60  GYNECOLOGY 

"Menstruation,  that  is,  the  periodic  emission  of  blood  by  the  uterine  mucous  membranes, 
depends  upon  the  presence  of  the  ovaries  and  the  development  of  the  uterine  mucosa,  and  not 
solely  upon  the  bursting  of  a  Graafian  vesicle.  In  the  greater  number  of  instances  there  is, 
both  before  and  during  the  bursting  of  the  vesicle,  a  determination  of  blood  to  the  ovary.  This 
is,  in  all  probability,  the  reason  why  ovulation  and  menstruation  are  frequently  coincident. 
Ovulation  may  take  place  in  accordance  with  a  specific  periodic  cyclic  process,  or  its  occurrence 
may  be  irregular;  as  a  general  rule,  however,  its  periodicity  coincides  with  that  of  menstruation. 

"In  more  than  a  third  of  instances  ovulation  and  menstruation  are  not  simultaneous. 
Ovulation  may  take  place  at  any  time,  and  is  not  necessarily  accompanied  by  uterine  bleeding. 
This  fact  snakes  it  appear  extremely  probable  that  conception  also  can  occur  at  any  time. 

"  Menstruation  may  take  place  without  ovulation.  At  the  period  when  the  ovaries  undergo 
senile  involution  they  sometimes  contain  normal  Graafian  folUcles  and  corpora  lutea,  which 
seems  to  show  that  the  process  of  ovulation  may  outlast  that  of  menstruation. 

"It  is  evident  from  the  above  statements  that  Frankel's  theory  of  the  dependence  of  men- 
struation upon  ovulation  and  upon  the  internal  secretory  function  of  the  corpus  luteum  is 
untenable." 

In  view  of  the  foregoing  contradictory  opinions  on  the  part  of  the  highest 
authorities  definite  conclusions  on  this  important  subject  must  for  the  present  be 
held  in  abeyance. 

Ovarian  Transplantation. — Perhaps  the  most  striking  evidence  that  the  ovary 
is  an  organ  of  internal  secretion  is  seen  in  the  effects  produced  by  implantation 
and  transplantation  of  ovarian  tissue.  By  these  experiments  the, ovarian  in- 
fluence by  direct  nerve  connection  is  excluded,  and  it  is  clearly  estabhshed  that 
the  ovary  secretes  a  substance  that  acts  chemically  on  distant  organs  through  the 
agency  of  the  blood-stream. 

Experimentation  has  shown  that  in  young  castrated  animals  the  genitalia 
may  be  made  to  develop  normally  at  the  time  of  maturity  if  ovarian  tissue  is 
implanted  under  the  skin.  In  female  baboons,  a  species  which  exhibits  a  men- 
strual function  similar  to  that  of  the  human  female,  menstruation  may  be  pre- 
served after  extirpation  of  the  ovaries  by  transplanting  the  glands  to  various 
parts  of  the  body.  Experiments  such  as  these  are  conclusive  proof  of  the  chemical 
influence  of  the  ovarian  secretion.  Much  work  has  been  done  in  the  transplant- 
ing of  ovaries,  and  reports  vary  considerably  as  to  the  anatomic  fate  of  the  trans- 
planted tissue.  Conclusions  from  the  reports  of  others  and  from  our  own 
observations  show  that  an  ovarian  graft,  if  it  "takes"  successfully,  continues  to 
live  and  functionate  for  a  time  and  then  gradually  becomes  converted  into  func- 
tionless  fibrous  tissue.  The  life  of  a  graft  depends  on  numerous  factors.  Auto- 
plastic grafts  that  have  been  removed  and  reimplanted  in  the  same  individual 
take  better  and  live  longer  than  do  homoplastic  grafts  in  which  the  gland  is 
transferred  from  one  subject  to  another  of  the  same  species.  This  is  due  to  the 
physiologic  antagonism  of  blood  and  tissue  that  exists  between  different  indi- 
viduals. Homoplastic  transplantation  is  more  successful  when  there  is  a  blood 
relationship  between  the  two  individuals  than  when  they  are  entirely  unrelated, 
for  in  the  former  case  the  physiologic  antagonism  is  less  intense.  The  success 
of  an  ovarian  graft  depends  to  a  certain  extent  on  the  length  of  time  between 
extirpation  and  transplantation.     Thus,  a  graft  that  is  made  immediately  is 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM 


61 


Fig.  21. — Ovarian  Transplant  in  Horn  of  Uterus  after  Six  Years. 

1,  New  vessels  that  have  formed  between  the  uterine  and  ovarian  tissues.  2,  Junction  of 
uterine  and  ovarian  tissues.     3,  Corpus  albicans.     4,  Atretic  follicle. 

Note  that  the  surface  of  the  ovarian  graft  did  not  become  adherent  to  the  surrounding  tissues. 

History  of  the  case:  Operation  May  3,  1910.  Double  salpingectomy,  with  transplantation  of 
ovarian  tissue  in  each  horn  of  the  uterus.  Both  ovaries  preserved.  Four  years  later  patient  re- 
ported that  she  had  a  miscarriage  at  three  months.  Statement  corroborated  by  attending  phys- 
ician, but  no  fetal  tissue  preserved  for  confirmation. 

Operation  June  6,  1916.  Hystero-oophorectomy  for  ovarian  cyst  and  pelvic  adhesions.  Both 
operations  performed  by  the  author  at  the  Free  Hospital  for  Women,  Brookline. 


62  ■  GYNECOLOGY 

more  favorable  than  one  where  the  gland  is  preserved  for  a  time  in  cold  storage 
or  where  it  has  been  treated  with  some  chemical,  such  as  iodin,  or  heated  for 
the  purpose  of  bacterial  sterilization.  The  location  of  the  graft  is  also  important 
for  the  maintenance  of  the  life  and  function  of  the  gland,  it  being  necessary  that 
the  tissue  in  which  it  is  embedded  should  be  sufficiently  vascular  to  insure  the 
establishment  of  a  new  blood-supply  to  the  gland. 

The  life  of  an  ovarian  graft  even  when  successfully  planted  is  quite  inconstant 
and  varies  from  two  or  three  months  to  a  year.  In  some  well  authenticated 
cases  it  has  extended  to  two  or  even  three  years. 

The  histologic  changes  that  occur  in  a  human  ovarian  graft  may  be  seen  by 
referring  to  the  drawing  (Fig.  21).  In  the  case  here  depicted  the  ovarian  tissue 
was  removed  six  years  after  autotransplantation  into  the  horn  of  the  uterus.  It 
will  be  seen  that  active  follicular  development  has  practically  ceased.  There  ar^ 
the  remnants  of  an  old  corpus  luteum  and  in  one  place  can  be  seen  a  small  atretio 
follicle.  No  primordial  follicles  are  visible.  This  was  evidently  an  unusually 
successful  graft,  as  is  demonstrated  by  the  well-marked  vascular  connection  estab- 
lished between  the  ovarian  tissue  and  its  new  host.  In  this  case,  as  always 
happens,  there  took  place  a  considerable  diminution  in  the  bulk  of  the  transplanted 
tissue.  Enlargements  frequently  noted  in  grafted  ovaries  are  from  our  personal 
observations  due  to  cystic  degeneration  of  the  follicles,  and  not,  as  some  claim, 
to  a  regeneration  of  the  ovarian  parenchyma. 

To  the  gynecologist  ovarian  transplantation  has  been  a  subject  of  peculiar 
interest,  in  that  it  seemed  to  promise  a  solution  of  many  difficult  pelvic  problems. 
Practical  results  have,  however,  up  to  the  present  time  been  disappointing,  but 
it  is  quite  possible  that  with  improved  technic  and  with  a  greater  knowledge  of 
the  physiology  of  the  ovarian  functions  some  of  the,  hopes  for  its  usefulness  may 
in  time  be  realized. 

In  the  treatment  of  sterility  ovarian  transplantation  in  the  human  female 
has  been  especially  disappointing.  A  number  of  successful  operations  in  animals 
of  heteroplastic  transplantation  have  been  reported;  as  in  the  following  experi- 
ment cited  by  Martin : 

"W.  E.  Castle  and  John  C.  Phillips  (70)  reported  in  Science,  1909  that  ovaries  were  re- 
moved from  an  albino  guinea-pig  about  five  months  old,  and  in  their  stead  were  introduced  the 
ovaries  of  a  black  guinea-pig  about  one  month  old.  The  albino  upon  which  the  operation  had 
been  performed  was  then  placed  with  an  albino  male  guinea-pig  and  six  months  later  bore 
two  black-pigmented  young.  In  many  hundreds  of  matings  of  albino  guinea-pigs  observed 
by  the  authors  only  albino  young  were  produced ;  so  there  seems  no  room  for  doubt  that  in  the 
case  described  the  black-pigmented  young  derived  their  color  from  the  black  animal  that  fur- 
nished the  ovaries." 

A  similar  result  in  the  human  female  was  reported  by  HalHday-Crom  in  1905, 
who  claimed  to  have  brought  about  pregnancy  and  a  full  term  child  by  engrafting 
in  the  uterus  of  a  castrated  woman  ovarian  tissue  from  another  woman.  Morris 
reported  a  similar  case  in  1906.     Numerous  reports  of  pregnancy  following  auto- 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  63 

plastic  grafting  of  ovarian  tissue  in  the  uterine  horns  after  complete  bilateral 
salpingectomy  have  appeared  in  the  journals.  In  most  of  these  cases  there  has 
been  a  history  of  abortion.  Most  of  them,  like  that  of  the  author  (page  61), 
lack  irrefutable  evidence.  We  have  performed  this  operation  many  times  with- 
out success  as  regards  the  maintaining  of  fertility. 

Ovarian  transplantation  has  been  used  in  the  treatment  of  women  who  have 
by  surgical  operation  suffered  the  loss  of  their  ovaries,  but  with  the  retention  of     , 
the  uterus.     The  operation  of  double  oophorectomy  without  removal  of  the  uterus    j 
is  to  be  deplored,  in  that  it  is  usually  followed  by  discomforting  pelvic  and  vaso-  j 
motor  sjTnptoms,  often  of  extreme  severity  and  long  duration.    Several  such  cases 
have  been  reported  in  which  transplantation  of  ovarian  tissue  from  another  woman 
has  been  done  followed  by  temporary  reappearance  of  menstruation  and  remission 
of  ablation  symptoms.    The  results  of  such  an  operation  are  extremely  inconstant, 
owing  to  the  difficulty  of  successful  grafting  in  heteroplastic  transplantation. 

It  was  stated  above  that  in  unmatured  animals  normal  development  of 
the  other  genitalia  follows  castration  if  the  ovarian  tissue  be  transplanted  in 
some  part  of  the  animal's  body.  In  a  similar  manner,  after  castration  of 
the  adult  hmnan  female,  genital  atrophy  may,  for  a  time  at  least,  be  prevented 
-arid  the  menses  continued  if  ovarian  tissue  is  reimplanted.  Such  a  result 
ensues  onty  if  the  uterus  is  left  in  situ.  Menstruation  in  these  cases  is  re- 
established usually  after  three  or  four  months  following  the  operation.  A 
Hke  result  may  be  obtained  less  constantly  by  transplantation  of  ovarian  tissue 
from  another  woman.  Here  again  the  procedure  of  grafting  has  only  a  limited 
field  of  usefulness,  for  it  does  not  ultimateh^  do  away  with  the  disadvantages  of 
remo\'ing  both  ovaries  and  leaving  the  uterus.  It  may  be  said  also  that  ovaries 
that  are  so  diseased  as  to  recjuire  removal  from  the  pelvis  are  not  usually  suitable 
for  implantation  in  some  other  part  of  the  body. 

The  most  promising  field  for  ovarian  transplantation  would  seem  to  be  in 
cases  where  hysterectomy  with  removal  of  non-diseased  ovaries  is  required,  in 
which  it  might  be  expected  that  the  engrafted  organ  would  supply  an  internal 
secretion  sufficient  to  prevent  ablation  sjTiiptoms  of  hot  flushes  and  other  vaso- 
motor disturbances.  The  operation  has  been  performed  many  times  by  different 
surgeons  whose  opinions  as  to  its  efficacy  vary  considerably.  Some  beheve  that 
ablation  sjonptoms  are  definitely  and  favorably  influenced  by  the  transplanted 
ovary;  others  have  found  it  of  little  benefit.  We  have  carried  out  the  procedure 
in  many  cases  and  have  carefully  followed  up  and  tabulated  the  results.  In 
our  series  of  cases  as  compared  with  hysterectomy  cases  with  total  ablation  of  the 
ovaries  we  have  found  practically  no  difi'erence  in  the  incidence  or  intensity  of  the 
surgical  menopause  symptoms.  It  was  our  custom  in  the  earher  operations  to 
transplant  ovarian  tissue  after  hystero-oophorectomy  in  the  leaves  of  the  broad 
ligament.  In  this  situation  the  ovarian  graft  in  several  cases  became  cystic  and 
painful,  and  in  one  instance  apparently  produced  distressing  moLimina  with 
vicarious  epistaxis.     In  the  later  operations  the  graft  was  inserted  in  a  pocket 


64  GYNECOLOGY 

made  between  the  abdominal  rectus  muscle  and  its  aponeurosis.  In  a  few 
instances  the  section  of  gland  became  more  or  less  periodically  enlarged  and 
tender,  due  undoubtedly  to  cystic  degeneration  of  the  follicles.  In  one  case  the 
gland  grew  rapidly  to  nearly  the  size  of  a  fist  and  then  suddenly  collapsed. 
Some  recommend  planting  the  ovary  in  the  subcutaneous  fat.  In  a  case  in 
which  this  method  had  been  used  and  which  later  came  under  our  observation 
the  ovarian  tissue  became  extensively  cystic,  spreading  through  the  fat  and  re- 
quiring several  operations  for  its  complete  removal. 

From  the  foregoing  experiences  our  conclusion  has  been  that  the  operation  of 
transplantation  after  hystero-oophorectomy  is  of  little  or  no  practical  value. 
When  the  graft  has  been  made  in  some  easily  accessible  place  the  operation  cannot 
be  followed  by  any  serious  harm,  and  in  certain  cases,  chiefly  for  sentimental 
reasons,  it  may  be  advisable. 

Our  observations  regarding  the  feasibihty  of  ovarian  transplantation  after 
hysterectomy  are  substantiated  by  Tuffier,  who  remarks  that  "where  the  uterus 
is  absent  ovarian  transplantation  is  of  no  value." 

There  is  a  possible  field  for  ovarian  transplantation  in  the  treatment  of  the 
functional  amenorrheas  of  young  women.  So  far  as  we  can  chscover  there  has 
been  practically  no  work  done  along  tliis  fine.  The  following  experiment,  per- 
formed by  the  author,  is  presented  not  as  conclusive  proof  of  the  value  of  the 
procedure,  but  as  an  interesting  suggestion  that  a  remedy  may  be  found  for 
a  difficult  gynecologic  problem: 

Two  amenorrheic  women  came  to  the  hospital  at  the  same  time.  One  of  them,  twenty-six 
years  of  age,  had  menstruated  only  a  few  times  in  her  life.  She  had  been  married  five  j^ears, 
without  children.  She  was  perfectly  developed  both  as  to  her  primary  and  secondary-  sexual 
characters.  The  second  was  a  young  woman  of  twenty-one  who  had  menstruated  onlj^  two 
or  three  times  in  her  life,  the  last  time  four  months  previous  to  her  coming  to  the  hospital. 
It  happened  that  there  was  at  the  hospital  at  the  same  time  a  woman  who  had  had  menorrhagia 
and  metrorrhagia  for  five  years  as  a  result  of  uterine  insuflficiency.  Repeated  cirretings  had 
been  of  no  benefit.  The  uterus  was  anatomically  normal.  The  Wassermann  test  was  negative. 
Inasmuch  as  a  hj^sterectonw  seemed  advisable,  it  was  determined  to  graft  ovarian  tissue  from 
the  menorrheic  woman  into  the  two  amenorrhoic  patients.  Accordingly,  during  the  hysterec- 
tomy on  the  last  named  patient,  sections  were  taken  from  the  ovar\'  in  which  there  was  no 
corpus  luteum.  These  sections  were  immediately  transplanted  into  the  anterior  cer\dcal  hp 
of  the  amenorrheic  patients.  The  first  patient  a  few  days  after  the  operation  had  a  perfectly 
normal  menstruation  for  the  first  time  in  three  years.  The  second  patient  menstruated  nor- 
mally in  about  twelve  daj^s  and  has  menstruated  regularh^  since  for  about  five  months. 

In  these  two  cases  the  action  of  the  ovarian  internal  secretion  was  apparently  exerted  by  a 
portion  of  ovarian  tissue  from  which  the  influence  of  the  corpus  luteum  was  excluded. 

Organotherapy. — The  therapeutic  value  of  extracts  of  ovarian  substance 
has  passed  beyond  the  stage  of  theory  and  speculation  and  is  now  an  estab- 
hshed  fact  beyond  all  doubt.  With  regard  to  the  nature  of  the  active  sub- 
stance, the  exact  location  in  the  ovary  of  its  manufacture,  and  many  other 
questions  we  are  still  considerably  in  the  dark.  The  earher  reports  of  the  use 
of  ovarian  extracts  were,  for  the  most  part,  discouraging,  but  in  recent  years 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  65 

better  preparations,  a  more  definite  knowledge  of  the  physiology  of  the  ovary, 
and  a  more  intelHgent  selection  of  cases  for  treatment  have  yielded  results 
that  are  not  only  satisfactory,  but  often  astonishing. 

The  value  of  ovarian  therapy  is  seen  in  the  treatment  of  patients  who  are 
suffering  from  functional  deficiency  or  absence  of  the  ovarian  internal  secretion. 
The  most  conspicuous  examples  of  this  are  those  who  experience  the  vaso- 
motor disturbances  of  the  natural  or  artificial  menopause,  the  symptoms  of  ' 
which  consist  chiefly  of  hot  flushes,  vertigo,  etc.  By  the  administration  of  a 
properly  prepared  extract  these  symptoms  are,  with  some  exceptions,  greatly 
benefited  or  made  to  disappear  entirety.  The  extract  is,  therefore,  of  the 
greatest  help  in  the  routine  postoperative  treatment  of  patients  who  have  under- 
gone hysterectonw,  at  least  80  per  cent,  of  whom  suffer  from  vasomotor  changes. 

Next  to  its  importance  in  menopause  cases  is  its  value  in  treating  j^oung 
women   with   functional   amenorrhea   and   oligomenorrhea.     Its   results   with-- 
these  patients  are  not  as  constant  as  in  the  first  class  of  cases,  but  its  use  is  here 
successful,  either  partially  or  completely,  in  the  majority  of  instances. 

A  third  type  of  cases  in  which  ovarian  therapy  is  surprisingly  efficacious  is 
represented  by  patients  suffering  from  deficient  circulation  of  the  external 
genitaha.  As  is  elsewhere  stated  (see  page  46),  animal  experimentation  has 
proved  that  the  ovarian  internal  secretion  has  a  specific  hyperemic  effect  on 
the  external  genitalia.  Substantiation  of  these  experiments  on  animals  is  seen 
in  the  beneficial  effect  which  ovarian  extracts  have  on  the  conditions  of  pruritus, 
kraurosis,  furunculosis,  and  other  affections  of  the  vulva  in  elderly  women  where  vy' 
the  local  disturbance  of  the  parts  is  due  to  inadequate  circulation. 

Aschner  has  been  able  to  produce  hemorrhage  and  even  hematometra  in  guinea-pigs  by  the 
injection  of  ovarian  extract.  He  finds  in  animals  thus  treated  that  the  ovaries-eontain  an  un- 
usual number  of  ripening  foUicles,  and  ascribes  to  this  phenomenon  the  hemorrhagic  congestion 
of  the  uterine  mucosa  and  the  hj^peremia  of  the  external  genitals.  Aschner  has  also  found  that 
placental  extracts  work  still  more  strongly  than  ovarian  extract,  and  suggests  that  they  be 
used  in  amenorrhea,  sterility,  and  climacteric  disturbances. 

In  the  treatment  of  the  foregoing  classes  of  cases  the  e\ddence  of  the  value 
of  ovarian  organotherapy  is  beyond  dispute,  and  is  entirely  substantiated  by  a 
large  experience  in  its  use  by  the  author. 

In  addition  to  these  three  types,  various  other  gynecologic  affections  are 
reported  to  be  greatly  benefited  by  ovarian  extract.     Burnam  has  had  marked 
success  in  treating  neurasthenic  under-par  women  in  the  preclimacteric  decade.  " 
Dannreuther  reports  success  in  bringing  a  patient  to  term  after  repeated  abor- 
tions, and  finds  the  treatment  helpful  in  the  hyperemesis  of  pregnancy. 

A  few  cases  have  been  reported  of  the  cure  of  sterihty,  but  its  efficac}^  in 
this  respect  is  extremely  doubtful. 

In  conditions  presumablj-  due  to  hypersecretion  of  the  ovaries  and  menor- 
rhagia,  as  one  would  expect,  organotherapy  is  of  httle  assistance. 

There  is  at  present  much  discussion  and  experimentation  in  the  matter  of 


66  GYNECOLOGY 

the  form  of  the  extract.  On  the  ahiiost  universally  accepted  theory  that 
mternal  secretion  of  the  ovary  is  manufactured  by  the  corpus  luteum,  most 
extracts  nowadays  are  made  from  the  yellow  body  of  either  pigs  or  cows.  On 
the  ground  that  the  corpus  luteum  of  pregnancy  is  more  stable  than  that  of 
ovulation,  it  is  considered  by  some  (Dannreuther)  of  the  greatest  importance 
that  the  preparation  be  made  from  pregnant  animals.  On  the  other  hand, 
the  author,  whose  results  compare  favorably  with  those  of  the  most  enthusiastic 
users  of  the  corpus  luteum,  has  employed  an  extract  from  the  entire  fresh  ovary 
which  he  has  found  equal  in  effect  to  the  lutein  extracts. 

The  use  of  ovarian  extracts  is  not  dangerous,  there  being  no  toxic  effects 
excepting  a  slight  disturbance  of  the  stomach.  Dannreuther  lays  consider- 
able-stress on  the  depressing  effect  of  continued  doses  on  the  blood-pressure. 
This  is  probably  more  noticeable  in  the  case  of  corpus  luteum  extract  than  in 
that  of  the  whole  ovary. 

The  dosage  is  the  same  whether  corpus  luteum  or  ovarian  extract  is  given, 
5  gr.  three  or  four  times  daily.  In  most  of  the  preparations  now  used  1  gr. 
of  the  extract  represents  6  or  7  gr.  of  the  fresh  ovarian  substance. 

It  is  of  absolute  importance  that  the  preparation  be  fresh,  the  use  of  stale 
extracts  probably  accounting  for  many  of  the  unsatisfactory  results  reported. 

It  is  quite  probable  that  with  a  better  chemical  knowledge  of  the  ovarian 
substance,  and  with  improved  methods  of  preparing  and  administering  the 
extracts,  there  will  in  time  be  a  notable  advance  in  the  use  of  this  already  in- 
valuable remedy.  There  is  no  doubt  that  in  the  change  from  the  ovaries  to  the 
commercial  extract  important  ingredients  of  the  ovarian  secretion  are  dis- 
turbed. That  only  a  part  of  the  full  effect  of  the  secretion  is  reproduced  is 
shown  by  the  fact  that  whereas  ovarian  therapy  is  eminently  successful  in 
treating  disturbances  of  the  menopause,  it  has  no  effect  on  stopping  uterine 
atrophy.  Moreover,  it  must  be  remembered  that  while  in  the  body  the  ovarian 
secretion  passes  directly  into  the  circulation,  ovarian  therapy  requires  that  the 
substance  pass  through  the  digestive  apparatus,  so  that  a  chemical  disturbance 
in  the  secretion  is  more  than  probable  (Bab). 

It  has  been  justly  asserted  that  most  of  the  work  thus  far  done  on  ovarian  organotherapy^ 
has  been  unscientific  in  character,  and  that  the  chnical  results  from  its  use  which  have  been 
reported  are,  therefore,  in  large  part  untrustworthy. 

The  lack  of  greater  progress  in  this  important  subject  is  due  to  certain  impeding  factors 
which  serve  as  a  serious  handicap  to  proper  scientific  investigation.  Foremost  among  these 
factors  is  the  vagueness  of  our  knowledge  of  the  physiologic  processes  of  the  pelvic  organs.  We 
are  secure  in  oxir  belief  that  the  ovary  is  an  organ  of  internal  secretion,  but  it  has  not  yet  been 
proved  conclusively  in  what  part  of  the  organ  the  secretion  is  manufactured.  Moreover,  we 
are  quite  at  a  loss  to  know  whether  the  secretion  of  the  ovary  acts  directly  on  the  organism  or 
whether  it  serves  only  as  a  balance  to  the  products  of  more  powerful  glands  in  other  parts  of 
the  body.  In  addition  to  our  ignorance  of  pelvic  physiology  we  are  greatly  hindered  in  the 
study  of  ovarian  extracts  by  the  fact  that  it  is  impossible  to  make  standard  tests  for  most  of 

1  The  material  of  this  section  is  for  the  most  part  taken  from  an  article  by  the  author  entitled 
"Ovarian  Organotherapy.     A  Preliminary  Report,"  Jour.  Amer.  Med.  Assoc,  vol.  Ixix,  No.  9. 


EELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  67 

the  clinical  reactions  for  which  administration  of  the  extract  is  chiefl^^  indicated,  animal  ex- 
perimentation being  inadequate  on  account  of  the  exclusive^  human  character  of  the  reactions. 
The  admirable  experiments  of  Frank  and  others,  showing  the  effect  of  ovarian  extracts  on  the 
uterine  tissue  of  castrated  animals,  are  valuable  in  proving  the  actual  existance  of  an  active 
internal  secretion  in  the  ovary,  but  they  do  not  lead  us  to  definite  information  as  to  the  effect 
of  the  ovarian  secretion  on  such  complicated  hmnan  phenomena  as  menstruation  and  the  vaso- 
motor symptoms  of  ablation. 

A  serious  handicap  in  the  study  of  ovarian  therapy  is  the  fact  that  the  nature  of  the  secre- 
tion is  not  3'et  kno\\Ti.  On  account  of  this  doubt  as  to  the  nature  of  the  potent  substance 
there  has  been  no  effective  standardization  in  preparing  the  various  extracts  used  clinically 
and  experimentally. 

As  a  result  of  our  deficient  knowledge  of  the  physiology  of  the  pehnc  organs  and  the  con- 
sequent hmitation  to  more  scientific  methods  of  research,  most  of  our  information  bearing  on 
the  subject  of  ovarian  organotherapy  has  been  derived  from  observations  made  in  a  somewhat 
haphazard  way  in  connection  with  the  cUnical  administration  of  the  numerous  commercial 
preparations  put  on  the  market  by  various  drug  firms. 

Thus  it  happens  that  there  is  a  very  wide  divergence  of  opinion  among  clinicians  in  the 
matter  of  ovarian  therapy.  Many  assert  that  the  administration  of  ovarian  substance  is 
entirely  valueless  in  any  condition.  Such  testimony  may,  however,  in  the  hght  of  recent  ex- 
perience be  disregarded.  The  chief  controversy  hes  in  the  question  as  to  which  part  of  the 
ovary  is  most  efficacious  therapeutically,  some  advocating  the  corpus  luteum  alone,  others 
the  entire  ovary,  while,  as  will  be  seen,  the  author  recommends  the  ovarian  substance  from 
which  the  corpus  luteum  has  been  excluded.  Experience  shows  that  all  these  three  prepara- 
tions have  essentially  similar  physiologic  effects  when  used  in  certain  conditions,  variations 
occurring  onl}^  in  the  intensiveness  of  the  results.  It  may  be  said  that  in  all  preparations  the 
most  striking  results  are  obtained  in  the  treatment  of  the  vasomotor  symptoms  of  the  meno- 
pause. All  of  them  will  benefit  a  certain  number  of  cases  of  amenorrhea  and  oligomenorrhea 
and  of  circulatory  disturbances  of  the  external  genitals.  It  seems  probable,  therefore,  that  the 
active  substance  is  the  same,  whether  the  extract  be  made  from  the  corpus  luteum  or  from  the 
rest  of  the  ovary.  Therefore  in  selecting  a  part  of  the  ovary  for  the  extraction  of  the  secretory 
substance,  it  is  a  matter  of  choosing  that  tissue  which  shall  yield  the  substance  in  greatest 
abimdance,  and  with  the  least  toxic  effect  on  the  patient. 

Present  knowledge  indicates  that  there  exist  both  in  the  corpus  luteum  and  in  the  atretic 
follicles  cellular  elements  identical  in  their  origin  from  a  specific  connective-tissue  structiu-e 
(the  theca  interna)  and  capable  of  producing  an  internal  secretion  which  is  important  to  the 
growth  and  normal  functioning  of  the  organism.  If  this  is  true,  we  have  a  basis  on  which  to 
found  a  rationale  for  ovarian  therapy. 

If  an  internal  secretion  is  manufactured  from  both  the  corpus  luteum  and  the  atretic 
follicles  by  cells  of  identical  structure,  extracts  made  from  the  corpus  luteum  alone  lack  that 
valuable  part  of  the  secretion  w^hich  is  derived  from  the  atretic  follicles.  Moreover,  it  is  im- 
possible to  tell  bj'  inspection  whether  a  given  corpus  luteimi  is  in  the  process  of  maturation  or 
at  the  height  of  its  development,  or  in  a  stage  of  involution  and  disintegration.  It  must  happen 
that  in  the  preparation  of  many  corpora  lutea  for  therapeutic  purposes  a  varying  number  are 
included  in  which  the  essential  cells  are  no  longer  active  as  organs  of  internal  secretion,  and  are 
actually  in  a  condition  of  dissolution.  We  should  expect,  therefore,  that  commercial  prep- 
arations of  corpus  luteum  would  present  a  wide  variation  in  their  therapeutic  effects,  and, 
owing  to  their  readiness  to  decompose,  would  have  a  special  tendency  to  become  toxic. 

On  the  other  hand,  if  the  preparation  be  made  from  the  whole  ovary,  including  corpus 
luteum,  stroma,  and  follicles,  the  important  follicular  secretion  is  not  lost.  Preparations  of 
this  kind  would  be  expected  to  be  more  stable  in  their  composition  and  more  constant  in  their 
effect  than  those  of  the  corpus  luteum  alone.  These  conclusions  have  been  amply  borne  out 
by  our  clinical  experience. 

Reports  regarding  the  results  of  ovarian  therapj'  are,  for  the  most  part,  inadequate  and 
contradictory.  We  shall,  therefore,  in  discussing  the  subject  confine  ourselves  to  observations 
made  from  personal  experience. 

In  estimating  the  comparative  merits  of  preparations  of  the  whole  ovary  and  those  of  the 


68  GYNECOLOGY 

corpus  luteum  alone,  most  of  our  observations  have  been  made  in  treating  the  vasomotor 
symptoms  following  hysterectomy.  In  this  type  of  case  the  corpus  luteum  showed  a  great 
variation  in  effectiveness,  often  being  entirely  valueless  and  occasionally  producing  digestive 
disturbances.  On  the  other  hand,  the  whole  ovary,  used  in  a  large  number  of  cases,  showed 
great  constancy  in  therapeutic  effect,  so  that  we  have  come  to  regard  it  as  almost  a  specific 
in  the  treatment  of  ablation  symptoms,  both  of  the  artificial  and  natural  menopause.  Striking 
results  have  also  been  obtained  in  the  treatment  of  functional  amenorrhea  and  in  the  circulatory 
disturbances  of  the  external  genitals,  such  as  kraurosis  and  the  discomforts  of  senile  atrophy. 

In  order  to  test  further  the  effect  of  luteal  preparations  compared  with  those  of  the  whole 
ovary  a  series  of  clinical  observations  was  undertaken  with  desiccated  corpora  lutea  of  preg- 
nant animals.  Numerous  cases  were  treated,  representing  hot  flushes  from  the  menopause, 
oligomenorrhea,  dysmenorrhea,  and  amenorrhea.  In  all  but  two  of  the  cases  toxic  symptoms 
of  a  digestive  nature  were  produced.  Preparations  from  both  the  cow  and  the  pig  reacted  in 
the  same  way.  The  symptoms  were  invariably  those  of  nausea  and  vomiting  following  one 
or  two  doses.  In  one  case  the  ingestion  of  one  5-grain  capsule  resulted  in  continuous  nausea 
and  occasional  vomiting  for  a  period  of  ten  days.  The  result  of  these  clinical  experiments 
cannot  easily  be  explained.  It  was  at  first  thought  that  the  effects  might  be  due  to  decomposi- 
tion of  the  extract,  but  fresh  preparations  produced  the  same  symptoms.  They  could  hardly 
be  due  to  anaphylaxis  on  account  of  the  high  percentage  of  patients  affected. 

These  observations  suggest  the  possibility  that  the  nausea  and  vomiting  of  pregnancy  may 
be  determined  by  the  toxic  effect  of  the  internal  secretion  of  the  gestative  corpus  luteum. 

In  view  of  the  favorable  results  obtained  from  the  whole  ovary  compared  with  the  corpus 
luteum  alone,  and  of  the  positively  bad  results  from  the  corpus  luteum  of  pregnancy,  we  next 
determined  to  try  the  effect  of  the  ovarian  substance  alone  minus  the  corpus  luteum. 

In  this  experiment  the  ovaries  of  pregnant  animals  were  chosen  partly  as  a  check  to  the 
experiment  with  the  gestative  corpus  luteum  and  partly  to  test  the  therapeutic  effect  of  the 
internal  secretion  of  the  atretic  folhcles.  It  was  thought  that  pregnant  ovaries  would  be  par- 
ticularly favorable  for  studying  the  follicle  internal  secretion,  owing  to  the  well-known  fact 
that  during  pregnancy  the  process  of  follicle  atresia  is  especially  active. 

The  results  with  this  substance  were  interesting.  The  toxic  effect  created  by  the  corpus 
luteum  of  pregnant  animals  was  entirely  absent,  thus  showing  that  its  poisonous  reaction 
could  not  have  been  anaphylactic  in  character.  The  new  substance  produced  results  similar 
to  those  of  the  non-pregnant  ovary,  but,  in  general,  more  striking.  This  was  especially  true  in 
the  treatment  of  vasomotor  symptoms  following  hysterectomy.  The  preparation  proved 
generally  successful  in  the  treatment  of  hot  flushes,  and  in  some  cases  of  amenorrhea,  dysmenor- 
rhea, intermenstrual  pain,  catamenial  nausea,  headache,  and  the  genital  discomforts  of  senile 
atrophy. 

From  observations  made  with  this  substance,  incomplete  as  they  are,  we  have  at  least 
suggestive  evidence  that  an  internal  secretion  is  elaborated  from  the  follicles  which  in  thera- 
peutic value  is  equal  to  and  probably  greater  than  that  produced  by  the  corpus  luteum. 

Determination  of  Sex. — An  important  problem  in  the  study  of  the  internal 
secretions  is  involved  in  the  question  of  the  determination  of  sex  and  the  differ- 
entiation of  secondary  sexual  characteristics.  The  stigmata  of  sex  have  always 
been  regarded  as  dependent  on  the  organs  of  generation.  Primitive  peoples 
even  to  the  present  day  have  considered  the  differences  in  sex  as  due  to  the 
influence  of  the  external  genitals,  the  breasts  in  women  being  also  regarded  as  of 
especial  importance.  The  ancient  students  of  medical  science  held  the  uterus 
responsible  for  the  peculiar  characteristics  of  woman,  and  the  word  hysteria 
(tjoT£,oo9,  uterus)  was  employed  to  express  the  unstable  nervous  manifestations 
to  which  the  female  sex  is  susceptible. 

In  more  recent  times  the  seat  of  femininity  was  transferred  from  the  uterus  to 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  69 

the  ovaries,  and  the  old  saying  of  Helmont,  "Propter  solum  uterum  mulier  est 
quod  est,"  was  changed  by  the  Cheran  to  "Propter  solum  ovarium  mulier  est 
quod  est." 

The  modern  knowledge  of  the  ductless  glands  and  their  influence  on  growth 
has  greatly  modified  the  old  ideas,  and  we  now  know  that  the  question  of  sex 
differentiation  is  not  as  simple  as  the  ancient  dicta  implied.  Virchow  believed 
that  all  the  peculiarities  of  mind  and  body  that  differentiate  man  and  woman 
are  dependent  on  the  generative  glands,  but  offered  no  explanation  of  the  fact 
that  individuals  possessing  the  glands  of  one  sex  frequently  exhibit  the  bodily 
and  psychic  characteristics  of  the  other  sex.  Modern  science  has  succeeded 
only  imperfectly  in  solving  the  riddle  of  sex  development,  but  enough  facts  are 
known  to  show  that  the  subject  is  exceedingly  complex  and  that  full  normal 
sex  growth  is  dependent  on  many  factors  in  which  probably  all  the  glands  of 
internal  secretion  play  an  important  role. 

Theories  regarding  the  origin  of  sex  may  be  grouped  under  three  headings: 

(1)  That  sex  distinction  is  predetermined  in  the  ovum  or  spermatozoon. 

(2)  That  sex  is  determined  at  or  immediately  after  fertihzation. 

(3)  That  the  sexual  cells  (ovum  and  spermatozoon)  are  undifferentiated  at 
the  time  of  fertilization  and  that  the  sex  is  not  determined  until  some  time  during 
embryonic  life. 

Biologic  investigations  reveal  that  sex  distinction  may  take  place  in  all  three 
ways.  Thus  in  certain  lower  forms  of  life  the  sex  of  the  eggs  laid  by  the  female 
is  influenced  by  external  conditions,  such  as  heat,  cold,  and  humidity.  In  other 
forms  the  female  lays  eggs  of  two  different  sizes,  the  larger  of  which  produces 
females  and  the  smaller  males.  In  each  of  these  cases  it  is  evident  that  the  sex 
is  determined  in  the  ovum. 

In  some  forms  of  insects  sex  is  determined  by  two  kinds  of  spermatozoa, 
being  dependent  upon  the  number  of  chromosomes  contained  in  the  nucleus  of  the 
sperm  cell.  In  this  case  the  cells  which  contain  an  accessory  chromosome  produce 
females;  the  others,  males. 

Biedl  quotes  authorities  who  claim  to  have  discovered  that  in  mammals  and  in  man 
there  exist  two  varieties  of  spermatozoa  which  have  distinct  staining  reactions  and  which  may 
possibly  represent  the  two  sexes. 

In  bees,  ants,  and  wasps,  to  quote  Biedl,  "the  conditions  are  different,  there 
being  only  one  kind  of  egg  and  one  kind  of  spermatozoon.  Males  are  produced 
by  parthenogenesis,  females  proceed  from  fertilized  ova.  The  queen  bee  is 
impregnated  once  only,  the  semen  being  retained  in  the  receptaculum  seminis. 
From  the  eggs  into  which  the  sperm  cells  penetrate,  females — that  is,  queens  and 
workers— are  hatched,  while  from  the  unfertihzed  eggs,  males^that  is,  drones- 
proceed.  Lenhossek  thinks  it  possible  that  the  sperm  cells  find  access  only  to 
those  eggs  which  possess  female  characteristics  and  that  they  do  not  penetrate 
the  male  eggs. 


70  GYNECOLOGY 

These  observations  show  that,  in  the  lower  forms  of  hfe,  sex  differentiation 
may.aheady  exist  in  the  unfertihzed  egg,  or  it  may  be  determined  in  the  course  of, 
or  immediately  after,  fertilization. 

In  the  higher  order  of  mammals  the  factors  that  determine  the  time  and  nature 
of  sex  differentiation  cannot  be  accurately  noted.  There  is,  however,  evidence 
to  show  that  in  them  the  process  corresponds  to  the  third  method  mentioned 
above,  by  which  differentiation  takes  place  at  a  considerable  time  after  f ertihza- 
tion  during  embryonic  life.  In  man  the  so-called  primitive  genital  trace  remains 
undifferentiated  until  the  fifth  week,  when  it  develops  into  a  definite  unisexual 
gland,  either  ovary  or  testis.  During  this  prehminary  period  it  is  assumed  that 
the  primitive  genital  trace  is  potentially  bisexual,  or  hermaphroditic,  from  the 
fact  that  in  rare  instances  true  hermaphroditism  may  occur  in  man;  that  is  to  say, 
elements  of  both  sexes  may  appear  in  the  gland  of  one  or  both  sides,  or  even  a 
male  gland  on  one  side  and  a  female  gland  on  the  other.  The  factor  which  deter- 
mines the  development  of  the  primitive  trace  into  ovary  or  testicle  is,  as  Biedl 
remarks,  absolutely  unknown. 

The  two  sexes  differ  in  other  respects  than  in  the  generative  glands.  Most 
important  are  the  excretory  ducts  of  the  glands  and  the  genital  apparatus,  in- 
cluding the  external  genitals  and  breasts.  These  are  rightly  termed  by  Biedl 
the  ''secondary  sexual  organs,"  for,  as  we  shall  see,  their  distinctive  development 
is  dependent  upon  the  nature  of  the  primary  genital  gland.  In  addition  to  these 
there  are  other  less  striking  though  marked  differences  in  practically  aU  of  the 
tissues  of  the  body,  such  as  skeletal  details,  distribution  of  fat  and  hair,  formation 
of  the  larynx,  consistence  of  the  skin,  muscular  development,  etc.  The  nervous 
and  mental  equipment  of  men  and  women  shows  a  decided  divergence.  All 
those  differences  between  the  male  and  female  exclusive  of  the  glands  of  genera- 
tion (ovary  and  testes)  may  be  regarded  as  "secondary  sexual  characteristics." 

Between  the  tissues  of  the  primary  and  secondary  characters  there  exists  an 
important  cellular  difference.  The  organs  of  generation  contain  the  germ  cells 
or  gametes  (ovum,  spermatozoon),  the  function  of  which  is  reproduction,  that  is 
to  say,  each  cell  is  capable  of  reproducing  a  complete  individual.  The  germ  cells, 
therefore,  possess  the  potential  of  immortahty.  All  the  cells  of  the  body  other 
than  the  germ  cells  are  called  "somatic"  cells.  These  make  up  the  various  organs 
and  structures  of  the  body,  and  are  mortal,  in  that  they  die  with  the  individual. 
It  is  quite  probable  that  all  the  somatic  tissues  of  the  body  possess  in  males  and 
females  secondary  sexual  differences.  To  those  structures  in  which  the  differ- 
ences are  apparent  is  applied  the  term  "secondary  sexual  characters." 

We  have  already  seen  that  the  sex  differentiation  of  the  primary  generative 
cells  may  take  place  in  several  ways,  in  human  beings  the  process  occurring  some 
time  after  fertihzation  and  manifested  by  the  development  in  the  fifth  week  of  a 
distinctive  gland  (ovary  or  testes)  from  the  primitive  genital  tract.  The  question 
then  arises,  Is  the  sex  of  the  somatic  cells  predetermined  in  the  ovum  or  is  it 
determined  later  by  the  nature  of  the  generative  gland  through  the  influence  of 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  71 

an  internal  secretion?  There  are  conflicting  views  on  this  point.  According  to 
Biedl  and  others  the  somatic  tissue  is  primarily  indifferent  and  does  not  begin  to 
show  differentiation  until  after  the  development  of  the  generative  gland.  A 
number  of  facts  support  this  view. 

In  the  early  embryo  there  is  no  sexual  distinction  in  the  secondary  genital 
organs.  The  primitive  Wolffian  and  Miillerian  apparatus  lie  side  by  side 
communicating  by  a  common  opening.  (See  section  on  Embryology.)  At  the 
end  of  the  third  month  one  of  these  two  systems  begins  to  develop  at  the  expense 
of  the  other,  according  to  the  nature  of  the  (now  differentiated)  generative 
gland;  the  Wolffian  developing  if  the  gland  is  male,  and  the  Miillerian  if  it  is 
female.  Whichever  system  gains  the  ascendency,  there  always  remain  rudiments 
of  the  other  even  in  full  maturity.  Thus  it  may  be  said  that  in  the  earliest 
beginning  the  individual,  as  far  as  the  secondary  genital  organs  are  concerned,  is 
completely  bisexual  and  that  the  ultimate  sex  is  determined  after  the  develop- 
ment and  under  the  influence  of  the  genital  gland.  The  same  process  doubtless 
characterizes  all  the  other  somatic  tissues  besides  the  genital  organs,  for  in  the 
newborn  there  are  numerous  well-defined  differences  of  organization  in  the  two 
sexes.  These  secondary  sex  characteristics  are  in  many  ways  firmly  estabHshed 
before  birth,  for  even  after  the  earliest  castration  the  male  always  remains 
distinctively  a  male  and  the  female  a  female  throughout  life. 

The  prevailing  theory  at  present  is  that  the  sex  differentiation  of  the  secondary 
genital  organs  and  of  the  general  secondary  somatic  characteristics  is  due  to  an 
internal  secretion  from  the  generative  gland.  It  is  also  believed  (chiefly  as  a 
result  of  the  researches  of  Tandler  and  Gross)  that  this  specific  internal  secretion 
is  elaborated  by  the  interstitial  cells  of  the  generative  gland,  that  is,  by  the 
cells  of  Leydig  in  the  testicle  and  by  the  analogous  interstitial  tissue  in  the 
ovary. 

An  apparent  contradiction  to  this  theory  is  the  fact  that  frequent  incon- 
gruities occur  between  the  nature  of  the  sex  gland  and  that  of  the  secondary 
characteristics.  Thus  it  often  happens  that  both  the  Wolffian  and  Miillerian 
systems  develop  more  or  less  equally  in  the  presence  of  an  apparently  unisexual 
generative  gland.  In  other  cases  the  secondary  sex  apparatus  may  be  pre- 
dominantly of  the  sex  opposite  to  that  of  the  gland.  These  represent  the  various 
forms  of  pseudohermaphroditism.  In  still  other  cases  individuals  with  normal 
primary  and  secondary  genitals  may  exhibit  marked  characteristics  of  the  other 
sex.  There  are  the  masculine,  hairy,  deep- voiced  women,  and  the  soft,  effeminate, 
beardless  men.  There  are  also  curious  cases  reported  in  which  there  may  take 
place  during  the  life  of  the  individual  an  almost  complete  alteration  of  the  sexual 
characteristics,  a  result  usually  of  some  injury  or  disease  of  the  genital  glands. 

According  to  Biedl,  the  various  manifestations  of  hermaphroditism  give 
evidence  that  the  primitive  genital  trace  from  which  the  ovary  or  testes  develops 
at  the  fifth  week  is  in  its  primordial  beginning  bisexual,  and  the  genital  gland  in 
its  development  may  retain  both  the  male  and  female  tissue  elements  that  elab- 


72  GYNECOLOGY 

orate  the  respective  internal  secretions.  This  condition  Biedl  names  glandular 
hermaphroditisjn,  and  calls  attention  to  itg  frequency  in  animals  even  of  the  higher 
orders.     Several  cases  of  so-called  "ovotestis"  have  been  demonstrated  in  man. 

Hence  hermaphroditism  is,  according  to  this  theory,  the  result  of  a  bisexual 
internal  secretory  mechanism  in  the  generative  gland,  and  the  irregular  secondary 
sex  characteristics  are  determined  b}^  the  special  activities  of  the  two  secretory 
tissues. 

We  may  sum  up  the  theory  of  sex  differentiation  as  expounded  by  Biedl  as 
follows : 

(1)  Sex  differentiation  may  be  determined  in  the  ovum  at  the  time  of 
fertiHzation,  or  at  a  considerable  time  after  fertihzation  during  embryonic  hfe. 
In  -the  human  race  it  takes  place  according  to  the  last  named  method, 

(2)  The  generative  gland  (ovary  or  testis)  is  developed  from  the  primitive 
genital  trace.  The  primitive  genital  trace  is  at  &st  bisexual,  as  is  shown  by 
glandular  hermaphroditism  (ovitestis).  The  influence  which  directs  the  primi- 
tive genital  trace  into  ovary  or  testis  is  absolutely  not  known. 

(3)  The  secondary  sexual  characteristics  including  the  secondarj^  genital 
organs  are  the  result  of  the  influence  of  an  internal  secretion  created  by  the 
generative  gland. 

(4)  Incongruities  between  the  sex  of  the  gland  and  that  of  the  secondary 
characters,  as  seen  in  the  various  forms  of  hermaphroditism,  are  presumably  due 
to  the  presence  in  the  gland  of  both  male  and  female  organs  of  internal  secretion 
(glandular  hermaphroditism). 

The  foregoing  is  interesting  chiefly  in  demonstrating  the  bisexual  character 
of  the  human  organism  in  its  earliest  embryonic  state.  It  does  not,  however, 
settle  the  question  as  to  the  predetermination  of  sex  in  the  ovum  or  sperm  ceU, 
for  it  does  not  even  suggest  an  explanation  of  the  cause  of  the  differentiation 
that  takes  place  in  the  primitive  genital  trace  in  the  fifth  week,  an  influence 
which  may  conceivably  date  back  to  the  germ  cell  before  or  at  the  time  of  fer- 
tihzation. 

It  is  quite  doubtful  if  the  determination  of  the  secondary  sexual  character- 
istics is  as  simple  as  Biedl  would  have  us  believe,  referring  them  as  he  does  entirely 
to  the  influence  of  the  internal  secretion  of  the  genital  glands.  Most  of  the  duct- 
less glands  have,  as  we  have  seen,  a  powerful  influence  on  growth  and  sexual  devel- 
opment. The  effect  of  tumors  of  the  suprarenal  cortex  in  evoking  male  secondary- 
characteristics  in  female  patients  is  an  example  suggesting  that  other  ductless 
glands  than  the  gonads  may  have  powers  of  sex  differentiation  and  that  her- 
maphroditism may  be  due  to  irregularities  in  the  general  internal  secretory 
system.  If  the  ductless  organs  are  to  a  greater  or  less  extent  sex  glands,  are 
they  themselves  sexually  differentiated,  and  if  so,  is  their  sexuality  primary 
or  secondary  in  relationship  to  the  gonads?  Such  questions  cannot  at  present 
be  answered. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  73 

THE   HYPOPHYSIS 

There  has  been  demonst  rated  a  most  intimate  functional  relationship  between 
the  hypophysis  and  the  sex  glands;  hence  the  subject  is  of  especial  interest  to  the 
gynecologist. 

In  order  to  understand  the  various  phenomena  produced  bj^  the  internal 
secretions  of  the  hypophysis  a  familiarity  with  its  anatomic  structure  is  essential. 

The  hj'pophysis  or  pituitary  body  is  situated  within  the  craniimi  at  the  base 
of  the  brain,  being  surrounded  by  a  bony  encasement  called  the  sella  turcica.  It 
is  connected  with  the  brain  by  the  infundibulum,  which  passes  through  an  open- 
ing in  the  dura  mater  lining  of  the  sella  turcica.  The  organ,  taken  as  a  whole  is 
flattened  anteroposteriorly  and  almost  completely  fills  the  ca^dty  of  the  sella 
turcica.  Its  weight  is  approximately  the  same  in  men  and  in  nulliparous  women, 
but  is  appreciably  increased  in  women  under  the  influence  of  pregnancy. 

The  hypophysis  consists  of  two  parts,  termed  the  anterior  and  posterior  lobes, 
which  exhibit  important  differences  both  in  histologic  structm'e  and  in  physiologic 
properties.  The  anterior  lobe,  which  constitutes  the  greater  part  of  the  organ, 
is  kidney  shaped,  concave  posteriori^',  firm  in  consistency,  and  has  a  character- 
istic pinkish-gray  color  in  the  fresh  state.  It  is  epithehal  and  glandular  in  struc- 
ture. The  posterior  lobe  lying  in  the  concavity  of  the  anterior  is  smaller  in  size, 
rounded  in  contour,  of  a  soft  consistency,  and  white  in  appearance.  Its  structure 
is  composed  of  nervous  elements.  Thus  the  two  lobes  are  often  spoken  of  as  the 
glandular  and  nervous  parts  of  the  hj^pophysis. 

Encasing  the  posterior  lobe  is  an  epithelial  lining  which  extends  upward 
along  the  infundibulum.  This  structure  is  designated  the  'pars  intermedia  and 
probabty  belongs  essentially  to  the  posterior  lobe,  with  which  it  forms  an  impor- 
tant physiologic  association  in  the  elaboration  of  a  specific  secretion. 

Histologically  the  anterior  lobe  is  composed  of  two  fundamentally  distinct 
types  of  epithelial  cells,  characterized  bj^  then-  difference  in  affinity  for  certain 
stains.  These  cells  in  consequence  of  their  staining  reaction  are  termed  chromo- 
phils  and  chromophobes. 

The  chromophils  have  a  definite  outline  with  a  homogeneous  protoplasm 
which  is  full  of  fine  secretion  granules.  These  cells  staiii  intensely  with  acid  or 
basic  stains,  hence  their  name. 

The  chromophobes,  on  the  other  hand,  are  ill-defined  in  outline;  they  do  not 
contain  secretion  granules,  and  have  no  special  affinity  for  acid  or  basic  stains. 
The  chromophobes  are  also  termed  the  chief  cells  (Hauptzellen) . 

The  posterior  lobe,  or  nervous  part  of  the  hypophysis,  consists  of  a  loose 
stroma  made  up  of  connective-tissue  elements  and  neurogha  in  which  the  latter 
is  in  excess.  It  is  invested  with  the  epithelial  j^ars  intermedia,  with  which,  ac- 
cording to  recent  theories,  it  is  structurally  connected. 

Clinically,  changes  in  the  anterior  lobe  produce  characteristic  reactions  in 
the  general  organism,  as  is  exemplified  by  such  diseases  as  giantism  and  acro- 
megaly.    The  functional  acti^dty  of  the  anterior  lobe  is  closely  interrelated  with 


74  GYNECOLOGY 

that  of  the  sex  glands.  Extracts  of  the  anterior  lobe  exercise  a  definite  influence 
on  the  sexual  apparatus.  Extracts  of  the  posterior  lobe  have  a  specific  action  on 
certain  unstriped  muscular  systems,  including  the  uterus. 

The  interrelationship  between  the  hypophysis  and  the  genitalia  has  been 
clearly  estabhshed  by  both  experimental  and  clinical  evidence.  The  earher 
experiments,  carried  out  notably  by  Gushing,  Biedl,  and  Aschner,  demonstrated 
that  deficiency  of  the  anterior  lobe  secretion  created  artificially  by  partial  removal 
of  the  organ  produced  genital  atrophy  in  adult  animals,  while  in  unmatured 
animals  it  brought  about  a  condition  of  permanent  genital  infantihsm. 

Gushing  found  in  animals  from  whom  the  anterior  lobe  ot  the  hypophysis  had  been  removed 
a  characteristic  picture.  The  animals  grew  very  fat,  the  genital  organs  of  adult  animals 
becoming  atrophied,  and  those  of  young  animals  remaining  undeveloped  and  infantile  in  type. 
In  time  there  ensued  polyuria  and  glycosuria,  falling  out  of  the  hair,  subnormal  temperature, 
and  lessened  resistance  to  infectious  diseases. 

Aschner's  experiments  consisted  of  total  and  partial  extirpations  of  the  gland  in  dogs  before 
and  after  sexual  maturity,  with  the  purpose  of  noting  the  anatomic  changes  in  the  reproductive 
organs.  The  operations  on  the  hypophysis  were  made  by  the  oral  route,  through  the  soft  palate 
and  cuneiform  bone.  The  dogs  which  had  been  operated  on  before  sexual  maturity  were  al- 
lowed to  live  until  several  months  after  the  time  of  normal  maturity,  and  were  then  compared 
with  normal  control  dogs  of  the  same  litter.  The  experimental  animals  showed  the  character- 
istic outward  disturbances  of  development  described  by  Gushing,  manifested  by  retarded  skel- 
etal growth,  accumulation  of  fat,  and  general  infantilism  of  the  various  organs,  the  internal  gen- 
ital apparatus  being  small  and  underdeveloped.  Histologic  examination  of  the  ovaries  showed 
retarded  and  incomplete  ripening  of  the  follicles  and  a  special  tendency  to  cystic  degeneration. 
The  uterus  remained  hypoplastic  and  infantile  in  character.  Heat  appeared  later  in  these 
dogs  than  in  the  normal,  and  only  in  rudimentary  degree,  with  slight  appearances  of  hyperemia 
and  uterine  secretion.  There  was  invariably  sterility  and  only  faint  manifestation  of  sexual 
impulse. 

Extirpation  of  the  hypophysis  in  mature  animals  showed  less  marked  changes  in  the  genital 
organs.  A  moderate  amount  of  degeneration  was  observed  in  the  ovaries,  while  the  uterus 
showed  very  much  less  atrophic  change  than  is  seen  after  castration.  Heat  was  not  entirely 
destroyed,  but  was  considerably  weakened. 

The  effect  of  removal  of  the  hypophysis  on  pregnancy  was  carefully  studied.  In  order  to 
remove  the  element  of  operative  shock  the  operations  on  gravid  animals  were  performed  in  two 
stages,  the  first  consisting  of  opening  through  the  bone  and  baring  the  dura,  while  in  the  second 
the  gland  was  extirpated.     Abortion  invariably  followed  the  second  stage  of  the  operation. 

Aschner  finds  less  marked  changes  in  the  genital  organs  after  his  operations  of  extirpation 
than  did  Gushing  and  Biedl  after  partial  removal.  Aschner  claims  that  the  difference  is  due 
to  the  fact  that  by  his  special  technic  less  injury  is  done  to  the  brain  substance  than  by  Gushing' s 
intracranial  method,  and  calls  attention  to  the  fact  that  lesions  of  various  portions  of  the  brain, 
cerebellum,  and  spinal  cord  may  produce  results  in  the  genital  system  similar  to  those  caused  by 
"extirpation  of  the  hypophysis. 

Further  experimental  evidence  of  the  relationship  between  the  hypophysis 
and  the  genital  system  has  been  afforded  by  the  physiologic  effects  of  various 
extracts  of  the  hypophysis.  Most  of  the  earlier  experiments  were  made  with 
extracts  of  the  posterior  lobe.  It  was  successively  discovered  that  these  extracts 
exercise  a  stimulating  action  on  the  musculature  of  the  uterus,  the  bladder,  and 
the  intestines.    Later  they  were  found  to  possess  a  definite  galactagogue  influence, 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  75 

acting  either  as  a  specific  stimulant  to  the  secreting  mammary  cells  or  as  a  con- 
strictor of  the  smooth  muscle-fibers  surrounding  the  milk  ducts. 

The  most  interesting  experiments  bearing  on  the  subject  have  been  recently 
published  by  Goetsch,  who  studied  the  effects  of  overstimulation  with  anterior 
lobe  pituitary  extracts  on  the  development  and  activity  of  the  sex  glands.  In 
view  of  the  retardation  of  genital  growth  produced  by  partial  extirpation  of  the 
anterior  lobe  Goetsch  reasoned  that  it  might  be  possible  to  create  premature 
sexual  development  by  the  prolonged  daily  feeding  of  anterior  lobe  extracts  to 
young  animals.  The  following  quotation  from  Goetsch's  article  summarizes 
the  results  of  his  experiments : 

''In  comparison  with  the  development  in  control  animals  the  ovaries,  tubes,  and  cornua 
of  the  uterus  of  animals  fed  with  whole  gland  extract  (in  which  the  anterior  lobe  is  the  respon- 
sible factor)  are  larger,  more  vascular,  and  edematous  in  appearance,  indicating  increased 
development  and  activity.  Even  at  the  early  age  of  two  and  two-fifths  months,  from  one  to 
two  months  before  normal  sexual  maturity,  the  ovary  is  matured,  and  shows  active  ovulation 
and  Graafian  follicle  formation,  relatively  few  primordial  follicles,  and  some  increase  in  the 
amount  of  interstitial  tissue.  This  striking  appearance  in  so  young  an  animal  gives  the  im- 
pression that  an  early  ovarian  maturity  has  been  produced  by  the  feeding  of  the  pituitary 
extract.  The  fimbriated  end  of  the  tube  is  more  branched  and  the  lining  columnar  cells  are 
more  ciHated,  an  indication  of  greater  activity.  There  is  marked  hyperplasia  of  the  uterine 
mucosa,  the  fining  cells  of  which  are  more  uniformly  ciliated  and  active,  and  there  is  abundant 
gland  formation  in  the  endometrium.  The  appearance  presented  by  the  latter  strikingly 
resembles  in  microscopic  appearance  the  hyperplastic  endometrium  of  early  pregnancy.  There 
is  generaUy  increased  vascularity  produced  in  the  whole  sexual  system.  The  overdevelopment 
is  apparent  even  in  the  muscle  coat  of  the  uterus,  which  is  considerably  thickened  and  is  also 
more  vascular.  A  somewhat  similar  change  is  produced  by  the  feeding  of  corpus  luteum  to  the 
female,  but  not  to  the  same  degree  as  after  anterior  lobe  administration. 

"And,  again,  the  feeding  of  pituitary  anterior  lobe  extract  to  rats  over  prolonged  periods 
was  studied  with  the  following  results:  After  prolonged  feeding  of  anterior  lobe  extract,  over 
a  period  of  eight  or  nine  months,  the  sexual  instincts  are  early  awakened,  along  with  the  early 
maturity  of  the  sex  glands.  As  a  result  of  this,  a  pair  of  rats,  after  anterior  lobe  feeding  over  a 
number  of  months,  bred  earlier  and  oftener,  the  female  of  this  pair  having  two  pregnancies  in 
seven  months  as  compared  with  none  in  the  female  of  the  control  pair.  The  effect  of  the  ante- 
rior lobe  feeding  lasts  through  the  adult  life  of  the  animals.  The  control  rat  never  reaches  the 
degree  of  development  and  activity  shown  by  the  animal  receiving  the  anterior  lobe  extract. 
For  even  at  the  age  of  ten  months,  after  eight  and  a  half  months  of  anterior  lobe  feeding,  the 
latter  still  shows  a  greater,  more  active,  and  mature  sexual  development  than  the  control. 

"The  feeding  of  pituitary  anterior  lobe  to  parent  rats  exerts  its  stimulating  influence  upon 
the  offspring  in  intra-uterine  life  and  during  lactation,  and,  when  the  experiment  is  carried  fur- 
ther and  the  feeding  to  the  young  is  continued  after  weaning,  it  has  an  even  greater  stimulating 
effect  upon  growth,  weight  and  development,  and  causes  earlier  and  more  frequent  breeding, 
and  an  increased  number  of  offspring  in  the  litters.  The  stimulating  effect  upon  the  sex  gland 
is  greater,  the  longer  the  influence  of  anterior  lobe  administration  is  exerted. 

"The  extract  of  pituitary  posterior  lobe,  even  after  prolonged  administration,  does  not 
stimulate  growth  in  general,  nor  the  development  of  the  sex  glands,  as  does  anterior  lobe  even 
after  a  very  short  period.  Thus,  for  example,  there  is  a  much  less  marked  development  of  the  , 
sex  glands  after  administration  for  two  and  a  half  months.  The  posterior  lobe  element  in 
the  whole  gland  extract  has  an  undoubted  retarding  influence  upon  the  development  of  the 
sex  glands,  an  effect  very  similar  to  that  of  ovarian  extract  upon  the  testes.  This  is  shown  by 
the  relatively  incomplete  development  of  the  testes,  for  example,  after  eight  and  a  half 
months  of  posterior  lobe  feeding.  If  given  in  too  large  doses  the  extract  causes  in  the  rats 
loss  of  weight,  a  mild  enteritis,  and  increased  intestinal  peristalsis." 


76  GYNECOLOGY 

Clinically  the  reciprocal  action  between  hypophysis  and  sex  glands  is  mani- 
fested in  numerous  ways.  Very  striking  is  the  influence  of  pregnancy  on  the 
size  and  weight  of  the  hypophysis.  Erdheim  and  Stumme  made  a  systematic 
study  of  the  hypophyses  of  women  who  had  died  during  pregnancy,  and  proved 
that  the  gland  always  becomes  hypertrophied  during  the  pregnant  state.  They 
showed  that  the  hypertrophy  takes  place  only  in  the  anterior  lobe  and  that  the 
posterior  lobe  not  only  does  not  share  in  the  overgrowth,  but  actually  suffers  a 
certain  amount  of  compression. 

On  section  the  gland  is  lighter  in  color,  is  softer,  and  on  pressure  exudes  a 
milky  juice.  This  change  in  consistency  is  the  result  of  a  surprising  change  in 
the  cellular  elements  of  the  anterior  lobe.  It  is  found  that  the  chromophobe  or 
principal  cells  have  been  transformed  into  an  entirely  new  cellular  type  called 
pregnancy  cells,  large  in  size  and  accumulated  in  enormous  numbers.  They 
are  arranged  in  broad  columns  and  alveoli  and  at  the  height  of  pregnancy  may 
assume  the  appearance  of  adenomatous  hyperplasia.  Cases  have  occurred  in 
which  the  hypertrophy  of  the  gland  has  been  so  great  as  to  exert  pressure  on 
"the  optic  chiasm  with  resultant  bitemporal  hemianopsia  (Goetsch).  The 
acromegaly-like  changes  in  the  face  and  extremities  that  occasionally  appear 
in  pregnant  women  are  thought  to  be  due  to  hypertrophy  of  the  anterior  lobe  of 
the  hypophysis.  After  birth  of  the  child  the  gland  undergoes  involution  in  a 
few  months,  though  the  number  of  chief  cells  or  chromophobes  remains  per- 
mantly  increased.  At  succeeding  pregnancies  the  reaction  is  intensified  and  after 
repeated  pregnancies  there  may  take  place  a  form  of  strumous  degeneration  with 
symptoms  of  hypophyseal  deficiency. 

The  author  recalls  two  cases  in  which  apparently  changes  in  the  hypophysis  became  patho- 
logic. In  the  first  case  a  young  woman  after  her  first  and  only  child  became  permanently 
amenorrheic.  Though  previously  thin,  she  began  soon  after  the  birth  of  her  child  to  accumu- 
late fat  enormouslj^,  so  that  in  time  she  had  the  appearance  characteristic  of  dystrophia  adiposo- 
genitalis,  the  result  doubtless  of  pressure  on  the  posterior  lobe  of  the  hypophysis.  The  breasts 
became  completely  and  permanently  atrophied.  At  the  age  of  about  thirty-five  she  developed 
a  cancer  of  the  body  of  the  uterus,  a  disease  which  commonly  does  not  appear  until  after  the 
menopause. 

The  second  case  was  one  of  a  woman  who  after  bearing  several  children  ceased  to  men- 
struate at  about  the  age  of  thirty-five.  There  ensued  an  increase  of  fat  and  partial  atrophy 
of  the  genitals.  Attention  was  called  to  a  probable  pituitary  change  by  the  typical  acromega- 
loid  appearance  of  the  hands,  which  the  patient  said  had  assimied  this  character  after  the  birth 
of  her  last  child. 

The  removal  of  the  sex  glands  produces  definite  changes  in  the  hypophysis. 
Fichera  first  described  an  enlargement  and  hyperfunction  of  the  organ  after 
the  castration  of  numerous  species  of  animals,  and  called  attention  to  an  increase 
of  chromophils  in  the  cells  of  the  anterior  lobe.  Tandler  and  Gross  demon- 
strated the  same  reaction  in  human  beings.  It  was  shown  that  eunuchs  usually 
possess  an  enlarged  sella  turcica  due  to  hypertrophy  of  the  hypophysis,  and  it  was 
pointed  out  that  the  skeletal  peculiarities  of  the  early  castrate  resemble  in  general 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  77 

those  seen  in  the  disease  giantism.  The  distrophic  deposition  of  fat  and  the 
anomahes  of  skin  and  hair  seen  in  eunuchs  recall  appearances  characteristic  of 
certain  forms  of  pituitary  disease. 

Tandler  has  demonstrated  an  enlargement  of  the  hypophysis  in  castrated 
women. 

It  has  already  been  suggested  that  the  hypophysis  is,  to  a  certain  extent,  a 
sexual  organ.  It  is  readily  conceivable  that  after  the  removal  of  the  sex  glands  in 
maturity  the  internal  secretory  function  of  stimulating  the  libido  is  carried  on 
by  the  hypophysis.  It  is  quite  possible  that  the  compensatory  hypertrophy  of  ' 
the  anterior  lobe  is  nature's  provision  for  carrying  out  this  purpose.  Support 
is  lent  to  this  idea  by  the  increase  of  the  sexual  impulse  that  often  follows  late 
castration,  a  fact  that  may  be  explained  by  overstimulation  from  the  hyper- 
trophied  sex  elements  of  the  anterior  lobe. 

The  relation  of  the  ovaries  to  the  hypophysis  is  well  illustrated  by  the  case  reported  by 
Goldstein  of  a  woman  who  in  her  youth  had  shown  some  tendency  to  giantism.  At  the  age  of 
thirty-eight  she  was  subjected  to  a  panhysterectomy  for  myomatous  uterus.  Soon  after  the 
operation  she  developed  a  very  marked  case  of  acromegaly.  In  this  instance  the  influence  of 
the  ovaries  had  held  in  check  the  strong  tendencies  of  the  hypophyseal  secretion.  When  the 
neutrahzing  effect  of  the  ovaries  was  removed  the  abnormal  tendency  of  the  hypophysis  was 
manifested  by  the  development  of  acromegaly. 

The  influence  exerted  on  the  sexual  glands  by  changes  in  the  hypophysis  is 
manifested  through  the  effects  of  increased  or  diminished  function  of  the  gland. 
Hyperf unction,  technically  termed  hyperpituitarism,  is  due  to  increased  activity 
of  the  anterior  lobe  consequent  upon  adenomatous  enlargement  or  hyperplasia 
of  that  portion  of  the  gland.  The  increased  secretory  activity  is  referable  to 
the  chromophil  cells  which  may  be  regarded  as  primarily  the  sexual  elements  of 
the  pituitary  organ.  If  under  the  influence  of  a  diseased  condition  hyperplasia 
of  the  anterior  lobe  occurs  before  puberty,  the  ultimate  result  is  gigantism.  If  i 
the  hyperplasia  takes  place  after  maturity,  acromegaly  ensues.  ^ 

During  the  early  hyperactive  stage  of  these  diseases  there  takes  place  an  | 
active  stimulation  of  certain  of  the  other  organs  of  internal  secretion,  notably 
the  sex  glands.  Thus  in  giants  there  may  be  a  precocious  acquisition  of  sexual 
power  and  secondary  sex  characters,  attended  with  abnormal  muscular  strength. 
Acromegalics  during  the  early  stages  may  exhibit  a  great  accentuation  not  only 
of  sexual  vigor,  but  of  all  their  intellectual  and  physical  powers.  In  the  course 
of  time,  however,  in  both  gigantism  and  acromegaly  the  overactive  tissue  of  the 
anterior  lobe  of  the  hypophysis  undergoes  a  regressive  change  in  the  form  of 
strumous  tumor,  with  tendency  to  cystic  degeneration.  Under  these  conditions 
the  once  hyperfunctionating  organ  is  transformed  into  one  in  which  the  function 
becomes  deficient.  A  corresponding  hypofunction  occurs  in  the  rest  of  the  organ- 
ism, especially  in  the  sex  glands.  Men  lose  their  libido  sexualis  and  become 
impotent,  while  women  become  amenorrheic  and  sterile.  Genital  atrophy 
eventually  occurs.     The  ovaries  of  acromegalic  women  show  atrophic  changes 


78  GYNECOLOGY 

on  the  part  of  the  Graafian  folHcles  and  interstitial  tissue  with  absence  of  corpora 
lutea. 

Hypofunction  of  the  hypophysis,  or  hypopituitarism,  as  it  is  called,  may 
occur  secondarily  as  in  gigantism  and  acromegaly  after  a  period  of  increased 
activity  or  it  may  be  primary.  Primary  hypopituitarism  may  be  the  result  of 
certain  inherent  degenerative  processes  or  more  commonly  the  outcome  of 
pressure  either  of  the  hypophysis  itself  or  of  a  neighboiing  organ.  If  it  occurs 
before  puberty  there  is  a  retardation  in  skeletal  growth  in  the  form  of  true 
dwarfism  in  contradistinction  to  the  condition  of  gigantism  which  follows  pre- 
pubertal hyperf unction  of  the  hypophysis.  Individuals  of  this  kind  possess 
typical  characteristics.  In  addition  to  the  undersized  stature  there  is  an  aplasia 
of  both  the  genital  and  interstitial  elements  of  the  genital  glands,  deficient  growth 
of  hair,  and  the  pecuHar  distribution  of  fat  referred  to  before  in  conditions  of 
dystrophia  adiposo-genitalis.  The  reproductive  organs  and  secondary  sex 
characters  are  infantile  and  there  is  a  general  sluggishness  of  metaboMsm  as 
indicated  by  polyuria.  There  may  be  symptoms  of  pressure  on  the  optic  nerve. 
In  other  words,  these  dwarfish  individuals  correspond  in  every  physical  respect 
to  the  experimental  dogs  of  Gushing  and  others,  in  which  the  anterior  lobe  of 
the  hypophysis  has  been  partially  extirpated. 

When  the  condition  develops  after  maturity  similar  though  less  marked 
changes  appear,  i.  e.,  adiposity,  hypotrichosis,  retrogression  in  the  sex  organs 
with  irregularities  of  function  and  various  abnormalities  of  metabolism. 

In  addition  to  the  well-defined  cases  of  hyper-  and  hypopituitarism  there  are 
cases  in  which  the  symptoms  are  confused  as  a  result  of  a  state  of  increased  and 
diminished  activity  occurring  in  the  same  gland  at  the  same  time.  To  such  a 
condition  has  been  given  the  term  dyspituitarism. 

Organotherapy. — From  a  therapeutic  standpoint  extract  of  the  posterior  lobe 
(pituitrin)  has  proved  of  the  greatest  value,  particularly  in  obstetrics.  Although 
the  extract  has  a  stimulating  influence  on  unstriped  muscle  generally,  it  seems 
to  exert  a  specific  action  on  the  parturient  uterus.  Pituitrin  acts  as  a  powerful 
stimulant  to  uterine  contractions  and  is,  therefore,  of  use  in  accelerating  labor 
and  in  preventing  postpartum  hemorrhages.  It  is  rarely  toxic,  but  it  is  attended 
with  certain  dangers  when  used  in  labor.  It  is,  in  general,  contraindicated  during 
the  first  stage  of  labor,  the  dangers  being  excessive  pains  on  account  of  the 
powerful  uterine  contraction  and  rupture  of  the  uterine  wall  if  there  is  weakness 
of  the  musculature  or  obstruction  to  the  labor.  Another  danger  is  asphyxiation 
of  the  child  in  cases  where  subsequent  rapid  delivery  cannot  be  carried  out. 
Pituitrin  produces  a  sudden  and  somewhat  prolonged  rise  in  blood-pressure  and 
in  some  cases  this  may  prove  dangerous  to  the  patient.  The  extract,  is  most 
useful  during  the  second  stage  of  labor,  in  cases  in  which  normal  progress  of 
labor  has  stopped.  By  its  use  many  low  forceps  operations  are  avoided,  while 
in  many  cases  in  which  high  forceps  would  ordinarily  be  necessary,  delivery  is 
brought  about  by  a  simple  low  forceps  operation. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  79 

In  the  postpartum  hemorrhage  pituitrin  has  not  taken  the  place  of  ergot. 
Williams  recommends  its  use  in  conjunction  with  ergot.  It  acts  more  rapidly 
than  ergot,  but  its  effects  are  more  transient;  hence  the  best  effects  may  be  pro- 
cured by  administering  pituitrin  first  and  following  it  later  with  ergot. 

Williams  also  recommends  pituitrin  as  a  prophjdactic  against  hemorrhage  in 
cesarean  section.  It  is  important  not  to  administer  the  drug  before  dehvery 
of  the  child  on  account  of  the  danger  of  asphj'xiation.  Immediate^  after  de- 
livery 1  c.c.  of  the  pituitrin  is  injected  directly  into  the  posterior  wall  of  the  uterus. 
The  uterus  undergoes  a  rapid  and  powerful  contraction. 

Pituitrin  has  become  a  useful  adjunct  in  the  treatment  of  intestinal  paresis 
and  distention  foUowing  abdominal  operations.  Some  even  go  so  far  as  to  employ 
it  as  a  routine.  The  first  dose  is  given  from  four  to  six  hours  after  operation,  and 
may  be  repeated  a  number  of  times  at  intervals  of  four  to  six  hours  according  to 
indications  (Goetsch).  We  have  found  it  useful  in  a  number  of  cases  of  severe 
distention,  and  in  two  cases  it  was  apparently  a  life-saving  measure. 

Pituitrin  is  said  to  be  valuable  for  stimulating  the  bladder  in  postoperative 
retention.  In  our  experience  it  has  proved  disappointing  when  administered 
for  this  purpose.  Pituitrin  is  usually  given  hypodermically  in  doses  of  1  c.c. 
from  sealed  ampules.  The  injection  should  be  intramuscular.  In  our  experi- 
ence we  have  never  noted  any  toxic  effects  in  its  use  for  postoperative  distention. 

Pituitrin  has  been  frequently  advocated  for  the  treatment  of  functional 
menorrhagias,  especially  in  those  that  occur  in  young  women.  We  have  found 
it  of  httle  or  no  value. 

Extracts  of  the  hypophysis  have  been  used  successfully  in  the  treatment  of 
patients  suffering  from  pituitary  deficiency.  As  Gushing  has  pointed  out,  in 
most  of  these  cases  both  lobes  are  affected.  The  loss  of  libido  and  potentia  in 
the  male  and  amenorrhea  and  sterility  m  the  female,  which  are  chai'acteristic 
of  hypophyseal  disease,  are,  as  we  have  seen,  referable  to  disturbances  of  the  ante- 
rior lobe,  while  the  accumulation  of  fat  and  metabohc  ^regularities  are  the  result 
of  defects  in  the  posterior  lobe.  Gushing  and  his  school,  therefore,  recommend 
for  the  treatment  of  these  cases  extracts  made  from  both  lobes  of  the  gland. 

In  gynecologic  practice  extracts  of  the  whole  gland  are  indicated  in  menstrual 
disorders  that  are  essentially  the  result  of  pituitary  deficiency,  in  which  cases 
ovarian  therapy  may  be  used  in  combination.  Goetsch  calls  attention  in  hypo- 
physeal therapy  to  the  importance  of  constant  and  long-continued  treatment 
with  increasing  dosage  for  successful  result.  He  recommends  beginning  with 
5  grains  of  the  dried  extract  of  the  whole  gland  thi-ee  times  daily  and  increasing 
this  dosage  until  improvement  is  noted. 

THE   THYROID 

The  variations  in  size  of  the  thyroid  gland  during  certain  phases  of  the 
female  sexual  life  has  been  observed  since  the  earhest  times,  but  only  recently 
has  the  subject  been  put  on  a  scientific  basis  by  exact  clinical  observations 
and  animal  experimentation. 


80  GYNECOLOGY 

It  has  been  observed  that  at  puberty  the  thyroid  at  times  takes  on  a  marked 
enlargement,  which  is  much  more  intensive  and  much  more  common  in  girls 
than  in  boys,  and  it  has  been  suggested  that  many  of  the  puberty  symptoms  in 
girls,  such  as  tendency  to  heart  palpitation  and  the  evidences  of  vasomotor 
disturbances,  may  be  due  to  a  hypersecretion  of  the  gland  at  this  period. 

Experiments  have  shown  a  certain  antagonism  between  the  ovaries  and  the 
thyroid  gland.  Animals  that  have  been  castrated  early  exhibit  an  abnormal 
length  of  certain  bones,  especially  the  tibia,  while  in  animals  from  which  the 
thyroid  has  been  extirpated  these  same  bones  are  excessively  short.  The 
early  extirpation  of  the  thyroid  produces  a  certain  amount  of  degenerative 
change  in  the  ovaries  or  testicles,  delays  the  time  of  puberty,  and  greatly  limits 
the  productivity  of  the  individual. 

It  has  been  well  estabhshed  that  the  thyroid  swells  during  menstruation, 
a  phenomenon  that  has  long  been  observed,  and  as  proof  that  this  is  not  due  to 
hyperemia  is  adduced  the  fact  that  sometimes  these  menstrual  swellings  are 
the  starting-point  of  permanent  goiters. 

Women  with  diseased  thyroids  usually  have  menstrual  disorders.  Kocher 
has  observed  that  patients  on  whom  a  too  radical  goiter  extirpation  has  been 
performed  suffer  from  menorrhagia,  and  has  treated  such  cases  successfully 
with  thyroid  extract.  He  terms  this  condition  menorrhagia  tMjreopriva.  That 
the  relationship  between  thyroid  and  genitals  is  not  understood  is  shown  by 
the  fact  that  in  some  cases  of  hypothyroidism,  or  myxedema,  there  is  amenor- 
rhea, and  that  thyroid  extract  works  beneficially  for  the  conditions  both  of 
menorrhagia  and  amenorrhea  when  the  gland  is  diseased. 

Interesting  clinical  observations  have  been  made  which  seem  to  show  some  definite  con- 
nection between  th>Toidism  and  menstruation.  Klokow  reports  the  case  of  a  seventeen-year- 
old  girl  who,  whenever  her  menses  were  delayed,  always  developed  a  goiter,  which  immediately 
vanished  as  soon  as  the  period  appeared.  Steinberger  reports  the  case  of  a  girl  of  sixteen  who 
suddenly  ceased  flowing  during  one  of  her  periods  and  at  the  same  time  developed  a  goiter. 
Treatment  with  iodin  caused  the  goiter  to  disappear,  whereupon  the  menstrual  flow  was  re- 
sumed. 

The  swelhng  of  the  thyroid  gland  is  most  noticeable  during  pregnancy, 
H.  W.  Freund  having  demonstrated  it  in  45  out  of  50  cases.  Lange  regards  the 
process  as  a  physiologic  one,  and  considers  it  due  to  hypertrophy  rather  than  to 
hyperemia  of  the  organ,  because  of  its  amenability  to  iodin  treatment. 

Lange  also  made  the  interesting  observation  that  women  in  whom  the 
thyroid  does  not  swell  exhibit  a  renal  albuminuria,  and  expressed  the  beHef 
that  the  swelhng  of  the  thyroid  acts  as  a  protection  against  certain  poisons 
which  are  set  free  as  a  result  of  pregnancy,  and  which,  without  the  protection 
of  the  secretion  from  th'e  hypertrophied  thyroid,  are  injurious  to  the  kidneys. 
As  a  rule,  the  enlargement  of  the  thyroid  gland  gradually  disappears  after  the 
end  of  pregnancy,  but  not  a  few  cases  have  been  reported  in  which  a  perma- 
nently increasing  goiter  dated  from  a  pregnancy. 


EELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       81 

The  thyroid  swelling  of  pregnancy  is  ordinarily  only  very  moderate,  but 
several  cases  are  cited  in  the  literature  by  Novak  where  the  goiter  became  so 
large  as  to  threaten  the  patient's  life,  necessitating  either  a  tracheotomy  or 
artificial  interruption  of  the  pregnancy.  During  labor  the  thyroid  is  said  to 
take  on  a  still  greater  enlargement,  which  in  a  few  cases  has  resulted  in  extreme 
dyspnea  and  death.  The  swelhng  of  the  gland  gradually  recedes  after  labor, 
though  it  has  been  observed  to  be  maintained  to  some  extent  through  the 
lactation  period. 

The  influence  of  the  climacteric  on  the  thyroid  gland  is  little  known,  and 
the  subject  is  largely  a  matter  of  speculation.  Several  instances  of  Graves' 
disease  have  occurred  at  the  climacteric,  and  have  led  to  the  suggestion  that 
the  neuropathic  and  vasomotor  symptoms  of  the  change  of  life  are  the  result 
of  hyperactivity  of  the  thyroid  gland. 

The  relationship  between  myomatous  uteri  and  thyroid  diseases  was  first 
remarked  by  W.  Freund  in  a  paper  written  in  1891.  Many  interesting  observa- 
tions have  been  made  on  this  subject,  but  the  relationship  cannot  be  very  con- 
stant, as  a  coincidence  of  the  two  conditions  is  certainly  not  particularly  com- 
mon. 

Glaessner  reports  the  case  of  a  woman  suffering  from  myoma  and  Graves'  disease  in  whom 
both  diseases  disappeared  at  the  chmacteric,  while  Frankel  cured  a  myoma  and  a  goiter  at  the 
same  time  by  the  use  of  the  x-rays.  Frankel  explains  both  these  cases  on  the  theory  that 
both  cures  were  due  to  the  injury  to  the  ovaries. 

The  most  recent  theory  connecting  uterine  myomata  with  the  thyroid 
gland  is  that  of  Neu,  who  attempts  to  account  for  the  heart  lesions  so  often 
found  in  long-standing  fibroid  cases,  a  condition  which  he  styles  the  ''myom- 
herz."  This  myoma  heart  he  regards  as  due  to  the  effect  on  the  heart  of  the 
thyroid  disturbance  with  which  myomata  are  sometimes  associated. 

Hjrperthyroidism. — Basedow's  disease  is  about  eight  times  as  common  in 
women  as  it  is  in  men,  and  occurs  chiefly  during  the  sexual  period  of  life.  It 
is  usually  associated  with  a  certain  amount  of  atrophy  of  the  genital  organs, 
which  is  often  manifested  by  amenorrhea  and  a  tendency  to  steriUty.  Sterility, 
however,  is  by  no  means  constant,  and  when  impregnation  does  occur  it  usually 
has  a  deleterious  effect  on  the  diseased  thyroid.  A  few  cases  have  been  re- 
ported in  which  an  intercurrent  pregnancy  has  exerted  a  favorable  influence  on 
the  disease,  but  the  general  experience  is  to  the  contrary. 

Exophthalmic  goiter  is  frequently  seen  associated  with  gynecologic  dis- 
ease, such  as  misplacements,  pelvic  inflammation,  etc.,  and  the  question  of 
operation  is  a  most  important  one.  It  may  be  said  that  the  disease  is  some- 
times made  worse  by  the  shock  of  a  surgical  operation,  and  that,  therefore, 
operative  measures  should  only  be  undertaken  in  cases  of  necessity,  or  when 
it  is  obvious  that  the  thyroid  disease  is  being  distinctly  aggravated  by  the 
pelvic  lesion. 
6 


82  GYNECOLOGY 

In  one  case  in  the  author's  experience  in  which  there  had  been  severe  dysmenorrhea  both 
the  patient's  general  condition  and  the  thyroid  disease  were  distinctly  improved  by  the  opera- 
tion; in  another  case  Graves'  disease  was  not  discovered  untU  after  the  operation,  which  un- 
questionably aggravated  the  disease  to  such  an  extent  as  to  make  it  definitely  noticeable. 

To  persons  suffering  from  exophthalmic  goiter  the  question  of  marriage 
and  reproduction  is  an  important  one.  It  is  necessary  to  take  into  considera- 
tion the  undoubted  fact  that  either  the  tendency  to  the  disease  or  ahied  neurotic 
conditions  may  be  transmitted  by  heredity,  while  the  danger  of  aggravating  the 
disease  by  pregnancy  is  a  matter  of  moment. 

H3rpoth5n:oidism  (Mjrxedema,  Cretinism  [Novak]). — Our  knowledge  of 
the  resulting  conditions  of  hypothyroidism  is  gained  from  animal  experimen- 
tation, operations  on  human  beings  for  goiter,  and  the  clinical  effects  of  absence 
or  destructive  disease  of  the  thyroid  gland. 

Removal  of  the  thyroid  of  young  animals  produces  constant  and  charac- 
teristic appearances,  consisting  of  an  immediate  limitation  of  growth,  especi- 
ally of  the  long  bones,  changes  in  the  growth  of  the  hair,  lowering  of  the  tem- 
perature, thickening  of  the  skin,  atheromatous  changes  of  the  aorta,  genital 
hypoplasia,  sterility,  and  idiocy  (v.  Eiselsberg). 

In  older  animals  the  changes  are  somewhat  less  marked  and  are  charac- 
terized b}^  apathy,  disturbances  of  the  skin  and  digestion,  emaciation,  anemia, 
and  lowered  resistance  to  disease.  The  genital  functions  are  diminished,  but 
not  always  entirely  destroyed. 

These  experimental  results  in  animals  correspond  very  closely  to  the  effects 
of  thyroid  removal  in  man,  when  all  the  gland  structure  (excluding  the  para- 
thyroid) has  been  extirpated.  The  condition  has  been  termed  "cachexia  strumi- 
priva"  (Kocher)  and  "postoperative  myxedema."  In  the  young  complete  re- 
moval brings  about  changes  similar  to  those  described  in  animals,  sexual  devel- 
opment being  either  entirely  prevented  or  much  delayed. 

Congenital  myxedema  or  thyreaplasia  relates  to  a  condition  where  there  is 
entire  absence  of  the  gland.  The  picture  is  characteristic  and  familiar — dwarf- 
ism, cretinic  facies,  peculiar  thick,  dry  skin,  broad  nose,  wide  nostrils,  and 
thick  lips.  There  is  very  marked  hypoplasia  of  the  genital  organs  and  mental 
defectiveness.  This  condition  is  said  to  be  hereditary,  being  influenced  by 
blood  relationship  or  alcoholism  of  the  parents.  The  disease  does  not  make  its 
appearance  until  the  second  half  of  the  first  year,  it  being  supposed  that  in 
uterine  life  and  during  the  lactation  period  the  child  receives  thyroid  secretion 
from  its  mother. 

Infantile  myxedema  is  the  result  of  an  early  atrophy  of  the  thyroid  gland 
in  children  who  are  born  normal,  and  remain  so  until  the  fifth  or  sixth  year, 
when  they  acquire  the  myxedematous  condition.  The  disease  is  far  more 
common  among  girls  than  boys.  The  genital  system  at  puberty  remains  in 
the  infantile  stage.  The  other  appearances  of  hypothyroidism  are  like  those 
of  congenital  myxedema,  only  not  as  severe. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  83 

Myxedema  of  adults  is  more  common  than  the  infantile  type  and  is  seen 
especially  in  certain  countries.  It  is  the  result  of  atrophy  of  the  thyroid  gland 
from  either  a  simple  or  inflammatory  process.  The  disease  is  characterized  by 
dryness,  thickness,  and  coolness  of  the  skin,  which  shows  swellings,  especially 
of  the  face,  neck,  and  extremities.  The  hands  look  plump  and  short,  the  eye- 
Hds  hang  down,  and  the  upper  hp  is  thick  and  protruding.  The  patient  be- 
comes apathetic  and  indolent.  The  speech  is  slow  and  expressionless.  Sweat 
secretion  entirely  ceases.  The  blood  is  reduced  in  red  corpuscles  and  hemo- 
globin (Novak). 

The  etiology  of  adult  myxedema  is  not  definitely  known.  Heredity  seems 
to  play  a  certain  role,  as  shown  by  examples  where  it  has  appeared  in  several 
members  of  the  same  family. 

The  disease  is  found  chiefly  in  women,  the  proportion  being  estimated 
as  high  as  80  per  cent.  In  a  very  large  number  of  cases  there  are  found  pelvic 
disturbances,  which,  however,  are  probably  rather  the  result  than  the  cause 
of  the  disease.  Severe  intrapartum  bleeding  and  too  frequent  chilclbearing  have 
been  assigned  as  etiologic  factors.  Sometimes  myxedema  develops  during 
pregnancy. 

The  special  genital  symptoms  that  occur  with  myxedema  are  usually  in  the 
form  of  menstrual  disturbance,  either  as  amenorrhea  or  menorrhagia,  for  both 
of  which  conditions  thyroid  extract  works  beneficially.  The  disease  does  not 
always  alter  the  genitaha,  but  may  cause  marked  atrophy. 

Another  form  of  hypothyroidism  is  seen  in  the  condition  of  endemic  cretin- 
ism, in  which  the  disease  is  associated  with  goiter  and  is  confined  to  certain 
localities.  The  etiology  of  this  affection,  usually  referred  to  drinking-water, 
cannot  be  discussed  here.  Hereditary  influences  unquestionably  play  some 
part  in  its  transmission. 

The  disease  manifests  itself  by  myxedema  and  disturbance  of  genital  develop- 
ment. As  a  rule,  the  genitals  preserve  the  infantile  type,  and  there  is  partial 
or  complete  lack  of  development  of  the  secondary  sexual  characters,  especially 
apparent  in  the  breasts  and  pubic  hair.  Sometimes  the  genitals  mature  nor- 
mally and  the  individual  may  procreate,  but  is  hable  to  dystocia  on  account  of 
narrow  pelvis. 

THE   PARATHYROIDS 

The  influence  of  the  parathyroids  on  the  organism  has  been  studied  experi- 
mentally in  animals.  It  has  been  found  that  in  all  animals  where  all  four  para- 
thjToids  are  removed  death  follows  from  acute  tetany,  while  a  partial  removal  of 
the  parathyroids  may  or  may  not  produce  a  condition  of  chronic  tetany.  The 
subject  is  of  interest  here  in  relation  to  the  tetany  of  maternity,  which  is  thought 
to  be  the  result  of  parathyroid  insufficiency.  Following  in  fine  with  animal 
experiments  in  which,  by  many  investigations,  successful  results  on  tetanized 
animals  were  obtained  by  the  implantation  of  parathyroid  tissue,  von  Eisels- 
berg  has  succeeded  in  effecting  a  permanent  cure  of  recurring  tetany  in  a  woman 


g4  GYNECOLOGY 

by  transplanting  a  parathyroid  gland  from  a  patient  who  was  undergoing  a 
goiter  operation.  The  results  of  parathyroid  extract  administration  in  cases 
of  tetany  have  so  far  not  been  particularly  encouraging. 

An  attempt  has  been  made  to  show  a  relationship  between  the  parathyroids 
and  the  conditions  of  eclampsia  and  osteomalacia.  Favorable  results  have 
been  reported  of  the  use  of  parathyroid  in  cases  of  eclampsia,  but  the  relation- 
ship has  not  been  scientifically  proved  and  is  a  matter  of  doubt.  The  same  may 
be  said  of  osteomalacia. 

THE   SUPRARENAL   SYSTEM 

A  knowledge  of  the  histology  and  comparative  anatomy  of  the  suprarenal 
system  is  essential  for  an  understanding  of  the  present  theories  regarding  its 
internal  secretory  functions.  Comparatively  recent  studies  have  shown  that  the 
suprarenal  bodies,  formerly  regarded  as  homogeneous  organs,  in  reahty  represent 
the  union  of  two  different  and  independent  organic  systems.  This  knowledge 
was  gained  first  by  the  frequent  discovery  of  small  bodies  isolated  from  the  main 
glands  which  from  their  histologic  structure  could  only  be  regarded  as  accessory 
parts  of  the  suprarenals.  Secondly,  comparative  anatomy  showed  that  in  the 
lower  vertebrates  the  two  tissues  which  constitute  the  cortex  and  medulla  of  the 
suprarenal  glands  exist  as  two  anatomically  separate  systems.  Furthermore, 
comparative  embryologic  studies  revealed  the  fact  that  two  independent  systems 
are  evolved  from  two  separate  primordial  beginnings,  which  in  the  higher 
vertebrates  become  topographically  united  in  the  form  of  a  single  gland. 

The  cortex  of  the  suprarenal  body  is  originally  derived  from  the  mesoderm 
and  is,  therefore,  a  connective-tissue  structure,  a  point  which  is  of  importance  in 
considering  its  relationship  with  the  glands  of  sex.  The  cells  of  the  cortex  are 
arranged  in  rows  and  columns.  Their  protoplasm  is  filled  with  fat  or  Hpoid 
granules.  The  cortical  cells  resemble  closely  the  interstitial  and  luteal  cells  of 
the  ovary  both  in  their  general  arrangement  and  in  their  possession  of  lipoid 
granules. 

The  medulla,  on  the  other  handj  is  derived  from  the  ectoderm  and  is,  therefore, 
an  epithelial  structure.  It  has  a  common  origin  with  the  sympathetic  nervous 
system  from  which  it  separates  in  the  process  of  embryonic  evolution.  The  cells 
of  the  medulla,  richly  supplied  with  nerves  and  vessels,  are  arranged  in  spheroid 
or  cord-like  masses.  They  have  an  affinity  for  chromic  acid  from  which  they 
receive  a  brownish  stain;  hence  they  are  called  chromaffin  cells. 

Thus  the  cells  of  the  cortex  are  distinguished  by  their  hpoid  contents  and  the 
cells  of  the  medulla  by  their  chromaffinity. 

Besides  the  two  suprarenal  capsules  there  are  to  be  found  isolated  cell  aggrega- 
tions in  certain  parts  of  the  body,  some  of  which  contain  cortical  and  others 
medullary  tissue.  Rarely  cell  bodies  are  found  containing  both  cortical  and 
medullary  tissue,  thus  constituting  true  accessory  suprarenals.  The  accessory 
cortical  cell  collections  are  found  in  the  neighborhood  of  the  suprarenals;  in  the 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       85 

renal  substance  itself;  along  the  suprarenal  veins;  throughout  the  retroperitoneal 
space  extending  down  into  the  pelvis;  in  the  broad  ligaments,  and  in  the  sex 
glands  (ovary  and  testes).  It  will  thus  be  seen  that  the  cortical  accessory- 
bodies  He  in  general  along  the  path  traveled  by  the  sex  glands. 

The  accessory  medullary  cell  accumulations  have  a  definite  independent 
distribution.  Inasmuch  as  the  medulla  of  the  suprarenals  had  a  common  em- 
bryonic origin  with  the  sjTiipathetic  nervous  system,  the  accessory  portions  are 
found  distributed  along  the  sympathetic  nerves  and  ganglia  partly  as  isolated 
cells,  partly  as  small  cell  bodies,  and  partly  as  glandular  structures.  The  last 
named  are  invariably  found  at  the  bifurcation  of  the  carotid  artery  and  at  the 
abdominal  division  of  the  aorta,  and  have  received  special  names  (carotid  gland, 
accessory  organs  of  Zuckerkandl) .  All  these  accumulations  are  made  up  of 
chromaffin  cells  like  those  of  the  suprarenal  medulla.  Hence  the  meduUa  with 
all  its  accessory  elements  is  termed  the  chromaffin  system.  Thus  it  will  be  seen 
that  the  cortical  portions  of  the  suprarenal  system  is  anatomically  closely  as- 
sociated with  the  urogenital  organs,  while  the  medullary  or  chromaffin  portions 
are  intimately  connected  with  the  sympathetic  nervous  system.  "With  this 
brief  description  of  the  anatomy  of  the  suprarenal  apparatus  it  wall  be  easier  to 
understand  its  otherwise  confusing  physiology. 

The  two  systems  of  the  suprarenal  apparatus,  cortical  and  medullary,  have 
each  an  independent  internal  secretory  function.  Most  of  our  present  knowledge 
of  the  specific  secretions  of  the  two  parts  of  the  suprarenals  relates  to  the  medul- 
lary or  chromafiin  system,  which  elaborates  the  hormone,  called  adrenalin  (or 
adrenin  or  epinephrin). 

Before  the  discovery  of  the  independence  of  the  two  parts  that  constitute  the  suprarenal 
organs  the  whole  glands  were  called  the  adrenals,  from  which  the  word  "adrenalin"  was  derived. 
In  the  modern  scientific  treatises  the  medulla  and  its  accessory  tissue  are  generally  referred 
to  as  the  adrenal  system.  This  nomenclature  is  apt  to  create  confusion  in  the  mind  of  the 
student.  In  contradistinction  to  the  adrenal  system,  the  cortex  and  its  subsidiary  tissue  is 
termed  the  "interrenal  systent"  In  order  to  prevent  confusion  we  have  purposely  avoided 
using  these  terms. 

The  physiologic  functions  and  chemistrj^  of  adrenalin  are  better  known  than 
those  of  any  other  hormone  of  the  body.  It  is  probably  necessary  to  the  Hfe 
of  the  organism.  Experimental  extirpation  of  the  medulla  does  not  always  cause 
death,  but  in  these  experiments  only  part  of  the  chromaffin  substance  is  removed, 
for  the  adrenal  function  is  carried  on  by  the  accessory  tissue  which  is  scattered 
throughout  the  body  in  association  with  the  sjTnpathetic  nerves  and  gangHa. 
These  free  portions  of  the  system  actually  comprise  collectively  a  mass  of  active 
functioning  tissue  considerably  greater  and  more  important  than  that  part  which 
is  enclosed  in  the  suprarenal  capsules,  namely,  the  medulla  (Biedl). 

Adrenalin,  owing  to  the  origin  and  distribution  of  the  chromaffin  tissue,  has  a 
specific  affinity  for  the  sjTnpathetic  nervous  system  and  exclusively  influences 
those  parts  of  the  body  which  are  ennervated  by  the  sjnnpathetic  system.     The 


86  GYNECOLOGY 

results  of  its  action  correspond  identically  with  those  produced  by  electric  stimula- 
tion of  the  sympathetic  nerves  supplying  those  organs  (Biedl).  Space  does  not 
permit  a  full  discussion  of  the  physiologic  significance  of  the  chromaffin  tissue. 
The  following  brief  summary  of  its  action  is  taken  from  Falta : 

"The  physiologic  significance  of  the  chromaffin  tissue  may  be  adduced  from  what  has 
just  been  said  with  regard  to  adrenalin's  intensive  and  manifold  actions.  We  may  assume  that 
it  maintains  the  normal  excitabihty  of  the  sympathetic  nerves  and  that  by  means  of  graduation 
of  the  secretion  it  is  concerned  in  the  regulation  of  the  blood-pressure,  the  distribution  of  blood, 
and  the  tonus  of  all  other  organs  innervated  by  the  symphatetic;  further,  that  it  maintains 
constant  the  amount  of  sugar  in  the  blood  and  enters  in  a  regulatory  manner  into  other  factors 
of  the  metaboUsm ;  further,  that  it  influences  muscular  power  (whether  directly  or  through  carbo- 
hydrate metabolism  is  questionable) ;  and  finally  it  exercises  an  influence  on  the  production  of 
neutrophilic  leukocytes  and  on  the  plasma  contents  of  the  circulating  blood." 

Of  especial  interest  is  the  fact  that  the  hormone  of  the  chromaffin  system  is 
greatly  influenced  by  conditions  of  emotional  disturbance.  Cannon  has  shown 
experimentally  how  such  emotions  as  fear,  anger,  desire,  etc.,  may  powerfully 
affect  the  output  of  adrenalin,  either  by  suppression  or  accentuation,  with  cor- 
responding changes  in  the  organs  innervated  by  the  sympathetic  system.  In 
view  of  the  emotional  lability  that  characterizes  woman's  nature  especially  at 
such  critical  periods  as  puberty,  menstruation,  pregnancy  and  the  menopause, 
and  the  organic  disturbances  that  occur  at  such  times,  there  undoubtedly  exists 
through  the  medium  of  the  emotions  an  important  relationship  between  the 
organs  of  generation  and  the  internal  secretion  of  the  chromaffin  system. 

The  following  quotation  from  Cannon  gives  an  excellent  idea  of  some  of  the 
interesting  work  he  has  done  on  the  relationship  of  the  secretion  of  adrenalin  to 
the  emotions: 

"When  a  cat  becomes  infuriated  the  pupils  are  dilated  and  the  hair  is  erect  from  the  neck 
to  the  end  of  the  tail.  But  besides  these  surface  manifestations  there  are  internal  changes; 
for  example,  the  heart  beats  rapidly  and  the  activities  of  the  stomach  and  intestines  are  stopped. 
Both  the  internal  and  the  external  changes  are  due  to  the  passage  of  nerve  impulses  to  viscera 
along  the  neurons  of  the  sympathetic  division  of  the  autonomic  system.  The  relation  of  the 
fibers  connecting  the  central  nervous  system  with  these  neurons  is  such  as  to  provide  for  diffuse 
action  on  all  the  viscera  that  are  innervated  by  this  division. 

"The  suprarenal  glands  are  supplied  with  nerves  from  the  sympathetic  division;  and  also 
the  secretion  of  the  suprarenal  medulla  affects  all  structures  innervated  by  the  sympathetic 
division  precisely  as  if  they  were  being  stimulated  by  its  impulses.  We  have  found  that  the 
suprarenal  glands  secrete  epinephrin  in  times  of  great  excitement,  that  there  is  an  increased 
Uberation  of  sugar  from  the  fiver  so  that  glycosuria  may  result,  that  there  is  an  abolition  or 
prompt  lessening  of  muscular  fatigue,  and  that  there  is  a  very  much  more  rapid  clotting  of 
blood.  It  is  known  also  that  epinephrin  causes  a  redistribution  of  blood  in  the  body  so  that 
it  is  sent  away  from  the  alimentary  canal,  whose  activities  are  inhibited,  to  the  heart,  the 
lungs,  the  central  nervous  system,  and  active  skeletal  muscles.  It  is  known,  also,  that  epi- 
nephrin causes  dilation  of  the  bronchioles,  and  it  is  known  that  it  increases  the  number  of  red 
blood-corpuscles  per  cubic  miUimeter — an  increase  which  Lamson  has  shown  occurs  also  to  a 
marked  degree  in  case  of  emotional  excitement. 

"These  changes,  as  true  of  man  as  of  the  lower  animals  in  times  of  great  emotional  stress, 
are  significant  when  the  conditions  which  would  give  rise  to  the  emotions  are  considered.    Fear 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       87 

is  associated  with  the  instinct  to  flee;  rage,  with  the  instinct  to  fight  These  are  the  emotions 
and  instincts  underlying  the  struggle  for  existence.  They  are  also  the  emotions  and  instincts 
into  which  all  other  instincts  may  be  readily  turned  when  they  are  thwarted.  The  internal 
changes  are  all  directed  toward  increasing  the  efficacy  of  the  organism  for  physical  struggle. 
The  increased  blood-sugar  provides  a  source  of  muscular  energy.  The  altered  distribution  of 
blood  and  the  increased  number  of  red  blood-corpuscles  arrange  for  carrying  an  abundance  of 
oxygen  to  the  active  structures.  The  dilated  bronchioles  allow  ready  ventilation  of  the  lungs 
when  oxjrgen  is  greatly  needed  and  carbon  dioxid  is  being  produced  in  large  amounts.  The 
provision  for  lessening  muscular  fatigue  is  directly  useful  in  muscles  likely  to  be  employed  in 
continued  action.  The  rapid  coagulation  of  blood  tends  to  preserve  that  precious  fluid  in 
case  of  injury  to  blood-vessels.  The  organism  in  which  these  changes  most  promptly  occur  has 
the  greatest  reinforcement  of  its  abilities  and  is  most  likely  to  be  favored  in  physical  struggle. 
These  arrangements  for  reinforcement  account  for  the  great  power  and  endurance  which  are 
exhibited  in  times  of  intense  excitement." 

Of  the  cortical  (or  interreiml)  part  of  the  suprarenal  system  unfortunately 
comparatively  little  is  known  at  present,  although  what  few  facts  are  at  hand 
lend  sufficient  evidence  that  it  bears  a  relationship  to  the  sexual  apparatus  of 
considerably  greater  significance  than  does  the  chromaffin  system. 

Experiments  testing  the  physiologic  action  of  extracts  of  cortical  substance 
have  not  up  to  the  present  time  produced  very  significant  results : 

"  R.  G.  and  A.  D.  Hoskins  have  carried  out  a  series  of  experiments  on  white  rats  in 
which  certain  of  the  young  animals  were  fed  with  desiccated  adrenal  gland  (Parke,  Davis  & 
Co.),  while  certain  others  were  kept  as  controls.  Forty-five  rats  were  fed  with  adrenal 
body  for  varying  periods  of  from  nine  to  twelve  weeks.  Twenty-six  animals  from  the  same 
litters  were  kept  as  controls.  The  rate  of  growth  and  the  weights  of  various  glands  were 
determined  in  each  series.  No  differences  between  the  two  series  could  be  detected  in  the 
case  of  the  kidneys,  heart,  pituitary  body,  thyroid,  thymus,  or  adrenal  bodies.  The  spleens 
of  the  experimental  series  were  somewhat  smaller  than  those  of  the  controls,  but  highly  va- 
riable in  size.  The  ovaries  in  the  few  cases  studied  were  larger  in  the  experimental  series. 
The  testes  (26  experimental,  13  control)  showed  hypertrophy.  These  results  indicate  that 
the  adrenal  bodies  exercise  a  stimulating  effect  on  the  growth  of  the  testes  in  young  ani- 
mals."    (Quoted  from  Vincent.) 

A  functional  relationship  between  the  sex  glands  and  the  suprarenals  was 
first  announced  by  Meckel,  who  observed  that  animals  endowed  with  the 
strongest  sexual  powers  are  also  possessed  of  markedly  developed  suprarenals. 
He  also  found  macroscopic  changes  in  both  glands  in  birds  and  amphibia  during 
the  rutting  period.  Meckel's  observations,  made  over  one  hundred  years  ago, 
have  to  a  certain  extent  been  confirmed  by  more  recent  researches. 

Defective  development  of  both  glands  is  often  found  associated,  a  result, 
doubtless,  of  their  original  proximity  in  embryonal  life.  Negroes  are  distin- 
guished by  a  greater  development  both  of  sex  and  suprarenal  glands  than  is 
seen  in  white  races,  a  fact  which  confirms  in  the  human  race  the  observations 
made  by  Meckel  in  animals. 

Further  evidence  of  the  correlation  between  the  two  glands  is  the  occasional 
appearance  in  the  realm  of  the  genitals  of  accessory  suprarenals  consisting  of 
cortical  and  even   chromaffin  tissue.     One  observer  has  demonstrated   chro- 


88  GYNECOLOGY 

maffin  tissue  in  the  ovary  itself.  In  hypoplastic  individuals  with  underdevel- 
oped sex  glands  a  diminution  of  the  suprarenals  has  also  been  noted,  though 
this  is  now  thought  to  be  not  a  specific  result  of  sexual  deficiency,  but  a  part 
of  the  general  hypoplastic  constitution.  In  the  condition  of  status  thymico- 
lymphaticus there  is  also  associated  hypoplasia  of  both  glandular  elements. 

Marine  emphasizes  the  similarity  between  the  cells  of  the  cortex  and  the  interstitial  cells 
of  the  ovary  both  as  to  structure  and  their  high  hpoid  content,  and  it  is  now  generally  believed 
that  the  interstitial  cells  of  the  sex  gland  play  an  important  part  in  the  development  and  main- 
tenance of  the  secondary  sexual  characters.  If  the  two  tissues  are  identical  it  is  probable  that 
the  cortex  also  influences  bodily  growth.  Strength  is  lent  to  this  theory  by  the  fact  that  both 
tissues  reciprocate  in  their  physiologic  hyperplasias.  Still  further  evidence  that  the  supra- 
renal cortex  influences  growth  is  seen  in  the  occurrence  of  cortical  hyperplasia  in  acromegaly. 

As  an  expression  of  hyperfunction  of  the  suprarenals  a  number  of  cases  of 
female  pseudohermaphroditism  have  been  reported  combined  with  the  pres- 
ence of  hypernephromata,  and  it  is  thought  that  there  is  a  probable  causal 
relationship  between  the  two  conditions. 

Numerous  cases  of  this  kind  have  been  reported.  To  this  list  is  added  the 
following,  for  which  the  author  is  indebted  to  Dr.  E.  A.  Codman,  in  whose  prac- 
tice the  case  occurred: 

The  patient,  a  woman  of  thirty-four,  had  been  married  five  years  and  had  no  children. 
As  a  girl  she  had  always  appeared  more  masculine  than  her  sister.  She  had  a  hairy  condition 
about  the  nipples,  under  the  arms,  and  in  the  middle  of  the  chest  like  a  man.  The  breasts  were 
atrophic.  She  had  also  had  hair  on  the  chin  sufficient  to  require  shaving.  The  genitals  were 
hypertrophied,  the  clitoris  looking  like  the  penis  of  a  boy  four  or  five  years  of  age.  There  was 
no  abnormality  of  the  vagina  and  later  at  operation  the  uterus,  ovaries,  and  tubes  were  found  to 
be  normal.  Her  catamenia  had  always  been  peculiar.  She  had  had  a  profuse  watery  kind  of 
discharge  as  a  rule,  but  in  1909  following  a  severe  shock  her  catamenia  became  normal  for 
three  months.     In  1915  it  stopped  altogether  and  had  not  appeared  since. 

In  September,  1916,  she  noticed  an  enlargement  just  below  the  right  costal  border  in  the 
region  of  the  liver.  She  was  seen  by  Dr.  Codman  on  December  19,  1916.  At  this  time  she 
had  a  very  large  tumor  extending  from  the  crest  of  the  ilium  upward  to  the  right  vault  of  the 
diaphragm  from  which  it  had  pushed  the  liver  over  to  the  left  side  of  her  abdomen.  The  tumor 
had  also  pushed  all  the  abdominal  contents  to  the  left  side  and  extended  a  couple  of  inches 
beyond  the  median  line  and  downward  well  below  the  umbilicus.  It  was  painless,  cystic  in 
feeling,  and  not  tender.  She  had  no  symptoms  except  a  shght  feeling  of  distention  after  meals 
and  some  loss  of  weight. 

An  operation  was  performed  by  Dr.  Codman.  The  operation  was  of  great  magnitude,  but 
was  successful  and  the  patient  made  an  excellent  recovery.  Microscopic  examination  showed 
the  tumor  to  be  made  up  of  cells  similar  to  the  cortical  tissue  of  the  suprarenal  body.  The 
character  of  the  tumor  was  malignant. 

The  after-history  of  this  case  is  extremely  interesting  in  that  it  shows  a  beneficial  effect  on 
the  secondary  sex  characters  after  the  removal  of  the  tumor.  The  following  is  an  excerpt  from 
a  report  by  Dr.  Codman: 

"The  result  of  the  case  of  Mrs.  W.  with  the  adrenal  tumor  was  extraordinarily  interesting. 
She  returned  to  my  hospital  on  September  2,  1917,  with  local  recurrence  in  the  scar  and  around 
the  vena  cava  and  kidnejr,  but  she  had  been  wonderfully  well  since  the  first  operation.  Greatly 
to  my  surprise,  I  found  that  the  secondary  sexual  changes  had  been  very  much  improved. 
The  hairy  condition  on  the  chest  and  even  on  the  chin  had  been  greatly  reduced.     Since  the 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       89 

operation  she  had  menstruated  regularly  with  a  normal  flow  for  the  first  time  in  her  hfe.  The 
breasts,  instead  of  being  perfectly  flat  like  a  male,  had  developed  to  a  moderate  size,  and  in  the 
upper  half  of  the  left  breast  was  a  tumor  which  I  took  to  be  a  chronic  mastitis.  It  was  like 
the  caked  condition  one  sees  during  menstrual  period  in  some  cas^s.  She  gained  30  pounds  and 
felt  well.  The  hypertrophy  of  the  genitals  was  much  less.  She  stated  that  she  had  never 
been  so  well  and  happy  in  her  life." 

On  account  of  the  extensive  recurrence  a  second  operation  was  undertaken,  but  the  disease 
had  involved  the  great  vessels  of  the  abdomen  to  such  an  extent  that  the  attempt  to  remove  it 
eventuated  in  the  death  of  the  patient. 

Hypernephromata  in  children  produce  precocious  sexual  development, 
most  of  the  cases  being  in  female  individuals.  These  children  show  a  special 
form  of  precocity,  in  that  there  is  an  abnormally  early  development  of  certain 
primary  and  secondary  characters,  such  as  the  external  genitals,  pubic  hair,  and 
general  bodily  form  without  symptoms  that  bespeak  a  true  function  of  the 
sexual  glands,  namely,  menstruation  or  ejaculation. 

In  general  it  may  be  stated  that  clinical  evidence  favors  the  view  that  when 
cortical  tumors  occur  in  the  female  an  accentuation  of  male  secondary  sexual 
characteristics  develops,  and  simultaneously  a  hypoplastic  condition  of  the  inter- 
nal generative  organs  supervenes  (Vincent). 

It  is  well  established  that  castration  is  followed  by  a  hypertrophy  of  the 
suprarenal  gland,  but  whether  this  represents  a  compensatory  process  for  the 
loss  of  the  ovarian  secretion  is  not  definitely  known.  Attention  has  been 
called  in  this  connection  to  the  close  similarity  between  the  corpus  luteum 
cells  and  those  of  the  suprarenal  cortex.  There  is  considerable  evidence  that- 
the  adrenal  tissue,  both  that  of  the  cortex  and  medulla,  is  hypertrophied  during 
pregnancy  and  probably  at  menstruation,  a  result  doubtless  of  increase  of 
function. 

Individuals  with  Addison's  disease  frequently  have  a  deficient  genital 
endowment,  which  is  regarded  as  a  part  of  a  general  constitutional  hypoplasia 
that  predisposes  to  the  acquisition  of  the  disease.  There  are  also  variations 
in  the  secondary  sexual  characters.  Addison's  disease  in  female  children,  as 
a  rule,  prevents  the  appearance  of  the  menses,  and  if  it  appears  in  adults  it 
manifests  itself  by  amenorrhea  as  one  of  the  earliest  symptoms,  a  matter  of 
considerable  diagnostic  importance.  Dysmenorrhea  and  menorrhagia  are 
very  rare  symptoms.  Individuals  with  Addison's  disease  rarely  get  pregnant, 
but  if  they  do,  abortion  or  premature  labor  are  apt  to  occur.  The  effect  of 
pregnancy  on  the  disease  is  a  deleterious  one. 

Pigmentation  of  Addison's  disease  appears  most  markedly  on  the  parts 
about  the  external  genitals,  and  may  be  confined  to  this  locality.  Of  diag- 
nostic interest  is  the  fact  that  pelvic  tumors,  especially  fibroids,  sometimes 
cause  pigmentation  of  the  skin  quite  similar  to  that  of  Addison's  disease. 


90  GYNECOLOGY 

PINEAL  GLAND  (EPIPHYSIS) 
The  pineal  gland,  which  in  some  animals,  notably  reptiles,  constitutes  a 
well-developed  organ,  is  in  man  comparatively  insignificant  in  size  (1  cm.  and 
0.5  cm.  broad).  Histologically  it  is  composed  of  a  few  glandular  cell  elements 
held  together  by  connective  tissue.  At  about  the  seventh  year  the  organ  begins 
a  process  of  involution  which  is  completed  at  about  the  age  of  puberty,  though 
a  small  amount  of  glandular  tissue  persists  throughout  life.  The  importance  of 
the  epiphysis  to  the  human  organism  is  variously  estimated.  It  is  of  historic 
interest  that  Rene  Descartes  regarded  the  structures  as  the  seat  of  the  soul. 
It  is  thought  by  some  that  it  is  only  a  "functionless  vestige  of  what  was  once  in 
earlier  evolutional  stages  a  functioning  eye."  That  it  is  an  organ  of  internal 
secretion  has  been  determined  chiefly  from  clinical  evidence  and  it  is  now  gen- 
erally accepted  that  the  organ  exercises  a  greater  or  less  influence  on  the  bodily 
and  mental  development  of  the  individual  and  upon  certain  nutritional  tissues. 
To  the  clinical  evidence  that  the  epiphysis  is  an  endocrine  gland  has  been  re- 
cently added  confirmative  proof  from  observations  on  the  growth  of  young 
animals  under  the  infiuence  of  pineal  feeding,  the  experiments  of  McCord  being 
of  chief  importance.  Earlier  deductions  regarding  the  action  of  pineal  secretion 
were  made  from  the  bodily  changes  created  by  tumors  of  the  pineal  gland  in 
children.  These  growths  are  rare,  only  a  few  having  been  reported.  They 
comprise  cj^st  formations,  gummata,  and  tumors  of  various  kinds,  including 
teratomata.  They  occur  chiefiy  in  males.  The  symptoms  are  both  local  and 
constitutional,  the  local  symptoms  being  due  to  intracranial  pressure  and  to 
encroachment  of  the  tumor  growth  on  neighboring  brain  structures.  The  con- 
stitutional symptoms  are  those  that  may  be  referable  to  disturbances  in  the  func- 
tional activity  of  the  pineal  internal  secretion.  These  consist  in  children  of  an 
abnormal  increase  in  bodily  size  and  of  a  precocious  development  of  the  sex 
organs.  The  sexual  precocity  is  characterized  by  acquisition  of  pubic  and  general 
body  hair,  and  in  boys  by  a  change  in  voice.  The  genitalia  and  secondary 
characters  of  a  boy  of  five  and  a  half  years  may  correspond  to  those  of  puberty, 
as  in  a  case  of  von  Frankl-Hochwart.  There  is  also  usually  a  precocious  psychic 
development  evidenced  by  prematurity  of  thought.  As  the  disease  progresses 
and  the  gland  becomes  completely  destroyed  cachexia,  decubitus,  etc.,  ensue. 

When  the  disease  occurs  late  in  childhood  or  during  adolescence  or  after 
maturity  it  is  characterized  by  excessive  obesity.  According  to  Marburg, 
hypopineahsm  leads  to  sexual  precocity,  hyperpineahsm  to  general  obesity,  and 
apinealism  to  cachexia.  Biedl  calls  attention  to  the  fact  that  there  must  exist 
an  antagonism  between  the  pituitary  and  pineal  glands,  for,  as  we  have  seen, 
pituitary  insufficiency  inhibits  sexual  development.  Falta  emphasizes  the 
similarity  in  sexual  precocity  that  exists  between  the  constitutional  effects  of 
tumors  of  the  pineal  gland  and  hyperplasias  of  the  suprarenal  cortex.  He  thinks 
it  possible  that  the  trophic  disturbances  of  the  pineal  glandular  tumors  infiuence 
the  cortical  system  and  cites  a  case  in  which  hyperplasia  of  the  cortex  was  found 
at  autopsy. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  91 

Experimental  evidence  regarding  the  internal  secretory  action  of  the  epiphysis 
is  meager  and  somewhat  contradictory.  Conclusions  from  extirpation  of  the 
gland  are  at  variance.  Dandy's  experiments  led  to  the  inference  that  the  pineal 
gland  is  not  essential  to  life  and  that  it  has  no  active  endocrine  function  of  im- 
portance to  the  animal's  well-being.  His  conclusions  coincide  with  those  of 
earlier  investigators.  The  more  recent  investigations  of  Horrax,  however, 
developed  that  pinealectomized  male  guinea-pigs  exhibit  a  premature  sexual 
development,  while  females  show  a  tendency  to  earher  breeding.  Horrax's 
results  are  in  keeping  with  those  of  C.  Foa,  who  found  after  extirpation  of  the 
epiphysis  in  young  fowls  a  very  marked  precocious  development  of  the  testes  and 
some  of  the  secondary  sexual  characteristics. 

The  clinical  and  experimental  observations  thus  far  described  lead  to  the 
inference  that  the  pineal  gland  secretes  a  substance  which  in  early  hfe  before 
involution  of  the  organ  inhibits  sexual  development,  and  that  such  development 
is  encouraged  by  conditions  of  hypopinealism.  It  would,  therefore,  be  expected 
that  the  administration  of  pineal  extracts  would  act  as  a  deterrent  to  sexual 
maturity.  Such,  however,  is  not  the  case,  as  is  shown  by  the  experiments  of 
McCord,  which  furnish  one  of  the  curious  incongruences  frequently  seen  in  the 
study  of  the  endocrine  glands.  In  a  recently  published  article  McCord  reports 
an  extraorchnary  premature  increase  in  the  testes  of  young  male  guinea-pigs  and 
an  earher  sexual  maturity  in  the  females  after  pineal  feeding.  Administration 
of  pineal  substance  to  tadpoles  produced  accelerated  growth.  In  unicellular 
organisms  (paramecia)  it  increased  the  rate  of  production  to  more  than  double 
the  normal,  and  in  larval  forms  (ranidse)  it  hastened  both  growth  and  the 
differentiation  of  specific  organs. 

THYMUS 

A  relationship  between  the  genital  system  and  the  thymus  has  long  been 
observed  in  the  involution  of  the  thymus  that  normally  takes  place  at  puberty. 
Animal  experimentation  has  shown  that  castration  of  young  animals  prolongs 
the  time  of  thymus  involution.  Other  observations  reveal  that  in  individuals 
with  hypoplastic  genitals  involution  takes  place  later  than  normal.  Status 
thymicus  is,  therefore,  associated  with  genital  deficiency.  Further  researches 
have  shown  that  castration  in  the  young  produces  no  observable  change  in  the 
structure  of  the  thymus,  but  that  castration  after  sexual  maturity  causes  a 
definite  enlargement  of  the  parenchyma. 

Extirpation  of  the  thymus  has  failed  to  prove  any  reciprocal  functional 
correlation  between  the  thymus  and  the  genital  glands. 

UTERUS 

It  has  been  suggested  that  the  uterus  produces  a  toxic  inner  secretion,  the 
harmful  influence  of  which  is  neutrahzed  by  the  presence  of  the  ovaries.  Such 
a  theory  would  account  for  the  deleterious  after-effects  of  double  oophorectomy 


92  GYNECOLOGY 

operations  where  the  uterus  has  been  left  in.      The  theory,  however,  has  no 
scientific,  basis,  there  being  no  evidence  nor  probabihty  of  a  uterine  internal 

secretion. 

PLACENTA 

In  the  first  few  days  of  birth  are  noted  certain  appearances  that  have  been 
referred  to  a  reaction  following  the  loss  of  placental  secretion,  and  described  as 
analogous  to  the  involution  processes  of  the  mother.  These  changes  in  the 
newborn  include  the  swelling  of  the  breasts,  from  which  comes  a  colostrum- 
like secretion,  and  in  females  a  hyperemia  and  enlargement  of  the  uterus,  which 
in  some  cases  may  result  in  a  discharge  very  hke  that  of  menstruation  (see  page 
18).i 

It  is  thought  that  the  placenta  exercises  a  very  important  influence  on  the 
mother  during  pregnancy,  and  that  after  the  primary  decidual  reaction  and 
nidation  of  the  ovum  the  various  pregnancy  changes  are  largely  under  pla- 
cental control.  We  have  already  seen  how  the  corpus  luteum  probably  prepares 
and  sensitizes  the  endometrium  for  nidation,  and  that  in  the  first  few  weeks  the 
life  and  growth  of  the  ovum  is,  to  a  certain  extent,  dependent  on  the  integrity 
of  the  corpus  luteum.  This  duty,  it  is  supposed,  is  then  assumed  by  the  pla- 
centa. That  the  ovaries  after  a  certain  period  are  of  little  moment  in  the 
progress  of  the  pregnancy  is  shown  by  its  uninterrupted  continuance  after  double 
oophorectomy. 

That  the  involution  process  after  labor  is  due  to  the  removal  of  the  placenta 
and  not  the  fetus  is  evidenced  by  the  persistence  of  pregnancy  symptoms  in 
cases  of  dead  fetus  and  hydatidiform  mole. 

The  most  important  recent  work  on  the  placenta  as  an  organ  of  internal 
secretion  has  been  done  by  R.  T.  Frank.  To  the  above  deductions,  which  were 
first  expressed  by  Halban  and  later  confirmed  by  other  investigators,  Frank 
gives  his  endorsement  and  contributes  additional  evidence  of  placental  internal 
secretory  action.  In  order  to  exclude  a  possible  ovarian  influence  Frank  ex- 
perimented on  castrated  animals.  He  found  that  subcutaneous  injections  of 
emulsions  or  solutions  of  placental  substance  cause  an  enormous  and  rapid 
hyperplasia  of  the  uterus,  the  weight  of  the  uterine  body  sometimes  reaching  five 
to  nine  times  that  of  the  normal  control  animal.  The  increase  takes  place 
within  six  to  eight  days  after  the  injection.  Both  the  uterine  musculature  and 
mucosa  share  in  this  hyperplasia.  The  same  reaction  may  be  evoked  in  trans- 
planted portions  of  the  uterus.  Furthermore,  the  action  is  not  changed  by  the 
removal  of  the  suprarenals,  pancreas,  or  thyroid,  or  by  the  combined  removal 
of  the  suprarenals  and  thyroid. 

A  similarly  rapid  and  pronounced  hyperplasia  is  produced  in  the  breasts  of 
rabbits  after  placental  injection,  and  if  the  stimulus  is  prolonged  colostrum  can 
be  expressed. 

1  This  last  phenomenon  may  be  the  result  of  maternal  ovarian  secretion  exerted  through  the 
medium  of  the  placenta. 


RELATIONSHIP    OF    GYNECOLOGY   TO    THE    GENERAL    ORGANISM  93 

Frank  found,  in  agreement  with  Herrmann,  that  "the  active  principles  ob- 
tained from  the  corpus  luteum  and  from  the  placenta  can  be  extracted  by 
identical  methods,  chemically  have  identical  properties,  and  biologically  produce 
identical  results  upon  the  uterus  and  breasts." 

Frank  believes  in  the  actual  complete  identity  of  the  two  substances  and 
suggests  that  ''the  placenta  may  act  merely  as  a  storage  reservoir  for  the  active 
principle  elaborated  by  the  corpus  luteum  during  the  earlier  part  of  pregnancy," 
calling  attention  to  the  fact  that  the  corpus  luteum  during  the  latter  half  of 
pregnancy  is  an  involuting  functionless  organ. 

RELATIONSHIP    OF    GYNECOLOGY    TO    THE    MAMMARY    GLANDS 

The  relationship  between  the  breasts  and  the  genital  organs  is  very  definite, 
but  little  understood. 

The  female  breasts  develop  rapidly  at  the  time  of  puberty.  In  many 
cases  they  become  enlarged  at  the  menstrual  periods,  while  during  pregnancy 
the  hypertrophy  is  of  a  marked  degree.  At  the  menopause  the  breasts  atrophy. 
In  what  way  does  the  cycle  of  development  and  function  of  the  breasts  depend 
on  the  function  of  the  genital  organs? 

The  old  theory  that  there  exists  between  the  mammary  glands  and  the 
genital  organs  a  specific  nerve  connection  has  been  exploded  as  a  result  of  more 
recent  experiments.  Galtz  and  Ewald  were  able  to  remove  a  large  part  of  the 
spinal  cord  of  a  bitch  without  interfering  with  normal  birth  and  secretion  of 
milk  in  the  breasts  with  ability  to  suckle  the  young.  Similar  observations  have 
been  made  in  women  who,  notwithstanding  a  complete  fracture  of  the  back, 
have  been  able  to  continue  nursing  their  children.  Pfister  and  Eckhardt  suc- 
ceeded in  dividing  all  the  afferent  nerves  to  the  mammary  gland  in  animals 
without  disturbing  the  secretion  of  milk,  while  Basch  reached  a  similar  result 
after  extirpating  the  celiac  ganglion  of  the  sympathetic  system. 

The  most  spectacular  experiment,  showing  that  the  function  of  the  breasts 
is  entirely  independent  of  any  nerve  connection,  was  performed  by  Ribbert, 
who  transplanted  the  breast  of  a  pregnant  rabbit  on  one  of  its  ears.  After 
the  rabbit  was  delivered  of  its  young  the  transplanted  breast  secreted  milk. 

It  has  further  been  shown  that  the  hypoplasia  of  the  mammary  glands  which 
usually  results  from  the  castration  of  young  animals  may  be  prevented  by  the 
transplantation  of  ovarian  tissue. 

From  these  and  other  experiments  there  seems  to  be  no  doubt  that  the 
changes  in  the  mammary  gland  are  due  to  the  circulation  in  the  blood  of  some 
chemical  substance  which  represents  a  true  hormone.  An  almost  positive 
proof  of  this  was  demonstrated  by  Schauta  in  the  case  of  the  Siamese  twins 
Blazek,  one  of  whom  became  pregnant  and  bore  a  normal  child.  After  the 
birth  of  the  child  both  sisters  secreted  milk  from  their  breasts.  The  same 
phenomenon  has  been  observed  by  Christea  in  parabiotic  rats  and  rabbits. 


94  GYNECOLOGY 

Although  it  seems  to  be  well  established  that  the  development  and  func- 
tion of  the  mammary  glands  is  presided  over  by  some  chemical  hormone,  the 
problem  of  the  source  of  this  secretion  has  not  yet  been  solved.  The  amount 
of  experimentation  and  speculation  has  been  very  extensive,  but  the  results 
have  been  conflicting  and  unconvincing. 

There  is  little  doubt  that  the  gro-^lh  of  the  breasts  at  puberty,  the  swelling 
at  the  menstrual  periods,  and  the  atrophy  at  the  climacteric  are  influenced  chiefly 
by  an  ovarian  secretion,  since  these  phenomena  do  not  appear  after  early  cas- 
tration. The  hypertrophy  during  pregnancy  and  the  secretion  of  milk  after 
delivery  seem  to  be  due  to  some  other  factor,  since  both  these  processes  con- 
tinue after  the  removal  of  both  ovaries  during  pregnancy,  and,  in  fact,  thej'' 
have  been  shown  to  be  dependent  in  some  way  on  the  suppression  of  the  ovarian 
function.  (The  milk  period  is  said  to  last  longer  after  castration,  while  in 
normal  women  the  return  of  the  menses  is  accompanied  by  disturbances  of  the 
milk  secretion.)  The  uterus  has  also  been  ruled  out  as  a  dominating  agent  in 
the  functions  of  the  breast  during  pregnane}^  and  childbirth. 

The  present  line  of  investigation  is  with  reference  to  the  influence  of  the 
fetus  and  the  placenta.  The  experiments  along  this  line  are  of  great  interest, 
but  the  results  are  inconclusive.  It  may  be  said,  however,  that  there  is  evi- 
dence to  show  that  the  chemical  influence  of  the  placenta  plaj^s  some  unex- 
plained part  in  the  process,  as  is  shown  bj^  the  following  experiments: 

Basch  injected  placenta  extract  into  virgin  bitches,  and  found  that  it  produced  no  changes 
in  the  beasts.  He  then  implanted  the  ovary  of  a  pregnant  bitch  in  the  abdominal  wall  of  a 
virgin  animal,  and  produced  a  hj'pertrophy  of  the  breast.  He  next  injected  placental  extract 
into  this  animal,  and  produced  such  an  intensive  secretion  of  milk  that  she  was  able  to  suckle 
a  litter  of  young  dogs. 

This  experiment  suggests  that  the  complete  cycle  of  mammary  hypertrophy  and  milk 
secretion  is  dependent  for  its  full  expression  on  both  the  ovary  and  the  placenta. 

There  has  been  adduced  no  evidence  to  show  that  the  mammae  possess  an 
internal  secretion. 

Extract  of  mammary  (mammin)  has  been  used  to  some  extent  for  the  con- 
trol of  uterine  bleeding.  There  seems  to  be  no  doubt  that  the  extract  does 
exert  some  specific  influence  on  the  uterus,  but  it  is  not  sufficiently  effective  to 
make  the  extract  of  much  practical  use.  Aschner  reports  success  in  16  out  of 
23  cases  treated  for  functional  menorrhagia  and  menorrhagia  due  to  adnexal 
disease,  fibroids,  and  uterine  insufficienc3^ 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE   SKIN^ 

There  is  an  important  connection  between  certain  skin  lesions  and  the 
physiologic  and  pathologic  processes  of  the  genital  organs.  The  changes  in  the 
skin  are  seen  most  markedly  in  those  periods  during  which  the  genital  organs 

^  Principal  authorities,  Troph,  Walthard,  McCarthy. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM       95 

undergo  special  activity,  namely,  the  age  of  puberty,  menstruation,  pregnancy, 
the  puerperium,  and  the  menopause.  (The  skin  manifestations  accompanying 
pregnane}^  and  the  puerperium,  though  important,  will  be  necessarily  omitted 
in  the  following  discussion.) 

Certain  pelvic  diseases  are  also  associated  with  skin  changes,  while  the 
external  genitaha  are  subject  to  well-defined  dermatologic  affections. 

Menstrual  Changes  in  the  Skin. — Menstruation  is  preceded  for  several 
days  bj^  an  increased  hyperemia  that  is  most  apparent  in  the  skin  of  the  cheeks, 
the  chest,  and  thighs.  This  can  be  seen  best  in  individuals  who  are  naturally 
pale.  The  hyperemia  recedes  during  the  period  and  is  succeeded  for  a  few  days 
by  an  unusual  pallor.  In  individuals  with  high  color  the  menstrual  hyperemia 
is  less  apparent,  but  can  be  recognized  by  observing  the  changes  in  those  parts 
which  are  normally  pale — around  the  eyes,  mouth,  and  chin. 

There  are  numerous  skin  eruptions  related  to  the  catamenial  period  which 
are  classified  under  the  term  "menstrual  exanthemata."  The  cause  of  these 
changes  is  not  definitely  known;  some  refer  it  to  the  influence  of  the  ovarian 
secretion  circulating  through  the  system;  others  see  a  reflex  or  trophic  disturb- 
ance in  the  innervation  of  the  skin. 

The  chnical  picture  of  menstrual  exanthemata  is  extremely  varied.  They 
may  be  discreet  or  diffuse,  localized  or  general,  urticarial,  vesicular,  macular, 
papular,  resembling  closely  the  appearance  of  erji:hema  exudativum  multiforme, 
or  even  of  erji:hema  nodosum. 

The  location  of  the  eruptions  is  usually  on  the  thighs,  abdomen,  and  breasts, 
but  they  may  occur  on  other  parts  of  the  bod}^  They  make  their  appearance 
several  days  before  the  onset  of  the  period,  and  either  disappear  at  the  cessation 
of  the  flow  or  last  for  several  days  after.  Occasionall}''  they  break  out  only  in 
the  intermenstrual  periods.  The  commonest  form  of  these  eruptions  is  the 
so-called  herpes  sexualis  or  menstruation  herpes.  This  appears  chiefly  about  the 
lips  and  nostrils,  sometimes  around  the  ears  or  eyes,  occasionally  on  the  breasts, 
fingers,  and  palms  of  the  hands.  It  may  also  affect  the  mucous  membrane 
of  the  mouth  or  the  vagina  and  vulva,,  and  has  been  described  as  invohing 
the  cornea  of  the  eye. 

Menstrual  herpes  may  be  accompanied  by  other  exanthemata  and  even  by 
bleeding  of  the  skin. 

Polland  describes  a  well-defined  eruption  that  he  terms  dermatosis  dysmenorrJwica  sym- 
metrica. This  is  a  disease  which  appears  only  in  women  who  suffer  from  menstrual  disturb- 
ances, chiefly  dysmenorrhea.  The  eruption  begins  -ndth  hjTJeremia  of  the  perifoUicular  vessels, 
followed  by  serous  or  bloody  exudation  and  the  formation  of  vesicles  on  the  epidermis.  Ordi- 
narily the  process  extends  over  only  a  few  days,  but  in  some  cases  there  is  necrosis  and  ulcera- 
tion, eventuating  in  a  scar.  The  eruption  may  be  abnost  universal  over  the  body,  but  it  is 
always  sjonmetric.  It  often  appears  at  puberty.  Polland  finds  that  the  disease  is  benefited 
by  ovarian  extract  (ovaraden  triferrin)  and  beUeves  that  it  is  due  to  a  disturbance  of  theanternal 
secretion  of  the  ovary. 


96  GYNECOLOGY 

Genital  herpes  is  seen  frequently  in  prostitutes  and  in  individuals  with 
great  sexual  irritability.  Its  occurrence  is,  however,  usually  closely  related 
to  the  menstrual  function.  A  purpuric  type  of  erythema  is  sometimes  seen  in 
the  form  of  ecchymoses  or  petechise  which  appear  several  days  before  menstrua- 
tion, and  are  often  swollen  and  painful. 

Another  form  of  hemorrhagic  skin  lesion  is  that  due  to  vicarious  menstrua- 
tion which  may  take  place  from  the  intact  skin,  from  various  mucous  mem- 
branes, and  from  scars,  wounds,  and  ulcers. 

Acute  edema  is  sometimes  seen  associated  with  menstruation  and  the  climac- 
teric, the  edema  occurring  chiefly  about  the  eyes,  in  the  lower  extremities,  or  in 
the  external  genitals.  Pemphigus  may  occur  in  young  girls  in  whom  menstrua- 
tion has  not  been  regularly  established  or  who  suffer  from  dysmenorrhea. 

Eczema  is  sometimes  seen  with  various  pelvic  diseases,  and  it  is  thought  by 
some  that  there  may  be  a  neurotic  relationship  between  the  two  affections. 
Eczema  at  the  time  after  the  menopause,  usually  appearing  on  the  scalp  and 
behind  the  ears,  occurs  sufficiently  often  to  be  regarded  as  a  specific  disease 
under  the  term  "climacteric  eczema." 

Eczema  of  the  external  genitals  and  surrounding  parts  is  very  frequently 
seen  in  connection  with  pruritus  and  various  pelvic  diseases  which  produce  an 
irritating  discharge.  In  this  case  the  eczema  is  the  result  of  chemical  changes 
in  the  skin  wrought  by  the  contact  of  the  harmful  secretions. 

Acne  is  a  very  common  manifestation  at  puberty,  though  less  frequent  in 
girls  than  in  boys. 

In  matured  women  who  are  affected  with  acne  there  is  usually  a  distinct 
relationship  between  menstruation  and  the  appearance  of  the  pustules.  Acne 
of  this  type  is  localized  chiefly  about  the  chin. 

Individuals  suffering  from  various  pelvic  disturbances,  especially  those 
that  lead  to  scanty  and  irregular  menses  or  to  leukorrhea,  seem  to  have  a  pre- 
disposition to  acne. 

Women  at  the  climacteric  also  frequently  suffer  from  acne  eruptions. 

Furunculosis  of  the  external  genitaha  is  sometimes  seen  as  a  chronic  disease, 
and  may  be  a  source  of  great  distress  to  the  patient.  The  chronic  or  constantly 
recurring  type  is  apparently  a  manifestation  of  deficiency  in  the  function  of  the 
ovaries,  by  which  the  local  resistance  of  the  external  genitals  is  lowered  toward 
pyogenic  organisms.  That  this  theory  is  probably  correct  is  shown  by  the 
curative  effect  of  treatment  with  ovarian  extract. 

A  certain  relationship  between  erysipelas  and  the  menstrual  function  has 
been  estabhshed,  cases  having  been  cited  in  which  there  have  been  periodic 
attacks  of  erysipelas  coincident  with  the  menses. 

There  is  a  very  close  and  well-known  relationship  between  pigment  hyper- 
trophy and  the  functions  of  the  pelvic  organs.  At  the  time  of  puberty  there  is 
a  physiologic  increase  of  pigment,  seen  especially  in  the  skin  of  the  external 
genitals,  about  the  nipples,  and  along  the  Hnea  alba.     During  pregnancy  the 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  97 

pigment  of  these  areas  is  markedly  hypertrophied,  while  irregular  spots  of 
brown  pigmentation  appear  on  the  face  (chloasma  gravidarum).  Increase  of 
pigmentation  is  often  seen  in  individuals  suffering  from  menstrual  disturbances, 
chiefly  amenorrhea  and  dysmenorrhea.  With  pelvic  tumors,  especially  the 
large  ovarian  cysts,  there  is.  often  a  noticeable  increase  of  pigmentation. 

Vitihgo  is  not  infrequently  seen  in  association  with  abdominal  tumors,  and 
is  thought  to  be  the  result  of  soiue  toxic  influence  issuing  from  the  tumor. 
This  seems  a  reasonable  theory,  as  the  removal  of  the  tumor  often  causes  a 
marked  improvement  in  the  appearance  of  the  skin  lesion. 

Postoperative  Eruptions. — One  of  the  commonest  -skin  affections  encoun- 
tered in  gynecologic  practice  is  the  postoperative  eruption  popularly  known  by 
the  somewhat  misleading  designation  of  "ether  rash."  This  does  not  refer  to 
the  temporary  erythema  frequently  seen  during  the  administration  of  ether, 
which  usually  disappears  by  the  time  the  patient  recovers  consciousness,  but 
represents  a  well-defined  disease  that  appears  from  a  few  hours  to  several  days 
after  the  operation  and  runs  a  short  but  characteristic  course.  Observations  of 
this  disease  are  scanty  and  the  etiology  obscure.  McCarthy,  who  has  most 
recently  studied  the  affection,  found  that  in  a  series,  of  1000  consecutive  opera- 
tive cases  at  the  Free  Hospital  for  Women  postoperative  eruptions  occurred 
43  times.  He  divides  the  cases  into  two  types-,  those  which  appear  within 
twenty-four  to  forty-eight  hours  after  the  operation,  and  those  with  a  later 
onset,  the  latter  following  a  more  definite  course.  He  describes  the  cases  with 
early  onset  as  exhibiting  an  eruption  on  the  upper  half  of  the  body,  beginning 
either  on  the  face,  chest,  or  arms  and  rapidly  involving  the  abdomen  and  legs. 
The  face  is  affected  in  almost  every  instance.  The  eruption  varies  in  charac- 
ter from  an  erythema  of  brief  duration  to  a  papular  type  lasting  for  several  days. 
Itching  is  the  most  marked  symptom.  There  is  little  systemic  disturbance 
beyond  a  mild  elevation  of  temperature.  In  the  second  class  of  cases,  which 
have  a  later  onset  of  three  to  s.even  daj^s  after  operation,  the  appearance  of  the 
eruption  is  sudden  without  prodromata,  excepting  that  the  temperature  chart 
has  usually  continued  higher  than  is  seen  in  the  ordinary  uncomplicated  post- 
operative convalescence.  The  condition  varies  in  severity,  from  that  in  which 
only  a  localized  part  of  the  body  is  affected  to  one  in  which  almost  the  entire 
body  surface  is  involved.  The  eruption  begins  as  a  fine  papular  efflorescence 
on  the  inner  surfaces  of  the  forearms  and  thighs  and  extending  over  the  body, 
rarely  including  th©  face  and  never  the  palms  and  -soles.  There  is  intense 
troublesome  itching,  which  persists  until  the  eruption  has  disappeared.  The 
papules  are  at  firet  pink,  but  may  later  assume  a  dark  reddish  hue.  The  course 
of  the  disease  reaches  its  height  in  twenty-four  to  thirty-six  hours,  and  then 
rather  rapidly  subsides,  the  average  duration  being  four  days.  McCarthy  notes 
that  those  cases  which  begin  on  the  third  or  fourth  day  after  operation  are  of 
the  longest  duration  and  of  greatest  severity.  The  temperature  remains 
slightly  elevated,  with  little  change  in  the  pulse.    There  is  also  a  moderate  leuko- 

7 


98  GYNECOLOGY 

cytosis  which  is  almost  constant,  and  shown  by  control  observations  to  be 
greater  and  more  persistent  than  that  frequently  seen  in  uncomplicated  con- 
valescence after  surgical  operation. 

Numerous  etiologic  factors  have  been  suggested  to  account  for  postopera- 
tive eruptions,  the  disturbance  being  referred  to  the  effect  of  ether,  calomel, 
magnesium  sulphate,  morphin,  and  various  substances  used  in  enemata.  Some 
have  attributed  the  rash  to  chemicals  used  in  laundering  hospital  linen.  Some 
have  ascribed  it  to  climatic  conditions.  Others  regard  the  disturbance  as  a 
manifestation  of  mild  undetected  sepsis,  or  to  the  absorption  of  tissue  destruction 
at  the  site  of  the  wound.  McCarthy  has  analyzed  all  the  causes  usually  given, 
and  finds  that  no  one  of  them  is  applicable  to  all  cases.  He  concludes  that  the 
affection  represents  a  vasomotor  disturbance  which  may  be  evoked  from  the 
sympathetic  nervous  system  by  a  variety  of  exciting  causes.  On  this  theory  he 
accounts  for  the  greater  frequency  of  these  eruptions  in  women,  whose  nervous 
organism  is  more  easily  disturbed  than  in  men.  The  theory  also  explains  the 
greater  frequency  of  the  eruptions  in  a  gynecologic  clinic  than  in  one  devoted 
to  general  surgery,  in  view  of  the  rich  supply  of  sympathetic  nerves  with  which 
the  female  pelvic  organs  are  endowed. 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE  ORGANS  OF  SENSE 

There  exists  between  the  organs  of  sense  and  the  genitalia  a  relationship 
of  considerable  definiteness,  the  most  marked  manifestations  being  connected 
with  the  function  of  menstruation. 

The  eye  may  undergo  various  functional  and  pathologic  changes  as  a  result 
of  genital  influences.  Vicarious  menstruation  following  suppression  of  the 
normal  function  may  appear  in  the  eyes,  with  extravasations  of  blood  in  the 
conjunctiva,  eye  muscles,  lens,  choroid,  retina,  or  even  in  the  optic  nerve. 
The  corresponding  disturbances  of  vision  disappear  with  the  absorption  of  the 
extravasated  blood  if  it  is  small  in  amount.  If,  however,  the  bleeding  has  been 
profuse  the  condition  may  be  followed  by  chronic  inflammatory  or  degenerative 
processes.  Even  in  the  presence  of  normal  menstruation  from  the  genitalia, 
hemorrhages  may  take  place  in  various  parts  of  the  eye  and  cause  more  or  less 
serious  disturbance. 

Other  pathologic  processes  sometimes  seen  in  the  eye  induced  by  the  in- 
fluence of  menstruation  are  eczematous  changes  in  the  lids,  herpes,  hordeola, 
inflammations  of  the  conjunctiva  and  cornea,  or  the  aggravation  of  already 
existing  inflammatory  conditions. 

Increase  of  the  pressure  in  the  eye  may  occur,  even  to  the  extent  of  glaucoma. 

Even  with  normal  menstruation  numerous  functional  disturbances  may  take 
place,  such  as  a  narrowing  of  the  field  of  vision,  dulness  of  vision,  weakness  of 
accommodation,  photophobia,  oculomotor  paralysis,  lessening  of  color  sense, 
etc.,  disturbances  which  may  be  much  more  marked  if  the  menses  are  ab- 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  99 

normal.  Such  functional  aberrations  may  sometimes  be  regarded  as  mani- 
festations of  psychoneuroses  in  nervous  individuals  during  a  period  when 
the  organism  is  peculiarly  sensitive. 

Secondary  anemia  from  severe  lo-ss  of  blood  from  the  genitals  may  be  fol- 
lowed by  anomalies  in  the  eye,  chiefly  in  the  form  of  edema  and  thrombosis, 
which  may  produce  permanent  degenerative  processes  in  the  retina  and  optic 
nerve.     In  this  way  bleeding  tumors  may  affect  the  eye. 

INIalignant  growths  of  tjie  pelvis  sometimes  metastasize  in  the  eye. 

Infectious  diseases  of  the  pehdc  organs  may  affect  the  eye  either  by  direct 
contact  with  the  infectious  material  or  by  embolic  processes  through  the  cir- 
culation. Of  the  former  method,  infection  from  gonorrheal  discharges  is  the 
most  familiar  example.  Diphtheria  may  also  be  transmitted  in  the  same  way. 
ISIetastatic  infection  of  the  eye  is  extremely  rare  excepting  in  connection  with 
puerperal  fever,  in  which  it  occasionally,  though  rarely,  occurs.  The  embolic 
focus  may  have  its  seat  in  almost  any  part  of  the  eye,  but  most  commonly  in  the 
.retina,  w^hence  it  may  extend  to  a  general  panophthalmia. 

Puerperal  sepsis  sometimes  causes  a  hemorrhage  in  the  eye  a's  a  result  of 
toxic  changes  in  the  blood  composition  and  a  greater  permeability  of  the  endo- 
thehal  walls  of  the  capillaries  (Mayer) . 

The  Ear.^ — What  has  been  said  regarding  functional  disturbance  of  the  eye 
during  menstruation  is  also  applicable  to  the  ear,  i.  e.,  certain  aberrations  .from 
the  normal  cases  may  be  referred  to  the  general  influence  on  the  organism  of  the 
menstrual  wave,  and  in  others  to  manifestations  of  psychoneurotic  impulses 
which  become  more  active  during  the  monthly  period  of  greater  sensitiveness. 

Existing  chronic  diseases  of  the  ear  have  been  observed  to  become  per- 
manently aggravated  by  pregnancy  and  childbirth. 

The  Nose. — Between  the  nose  and  the  genital  organs  there  exists  a  curious 
interrelationship  which  in  some  cases  is  quite  inexplicable.  The  .sense  of  smell 
is  one  of  the  most  powerful  sexual  excitants.  Marked  changes  in  the  nose 
are  often  seen  during  the  menstrual  period.  Vicarious  menstruation  is  more 
often  manifested  by  bleeding  from  the  nose  than  from  any  other  part  of  the 
body.  Individuals  who  menstruate  normally  are  often  prone  to  epistaxis  dur- 
ing the  period.  During  the  time  of  puberty  nose-bleeds  are  very  common. 
Anomahes  of  secretion  are  often  seen  at  the  time  of  catamenia,  and  may  consist 
either  of  acute  nasal  catarrh  with  profuse  secretion  or  of  abnormal  dryness  of 
the  nasal  mucous  membrane.  Disturbances  in  the  sense  of  smell  are  some- 
times observed  during  menstruation,  e\'inced  usually  bj^  an  increase  of  sensitive- 
ness or  by  perversions. 

Nasal  affections  during  the  catamenial  period  are  much  more  common 
in  those  whose  menstrual  function  is  not  normal,  appearing  with  especial  fre- 
quency in  w^omen  who  suffer  from  dysmenorrhea.  They  are  also  more  frequent 
in  neurotic  individuals.  What  was  said,  therefore,  regarding  the  functional 
-disturbances  of  the  eye  and  ear  applies  also  to  the  nose. 


100  GYNECOLOGY 

Cohabitation  is  ■sometimes  attended  with  acute  swelUng  and  discharge  from 
the  nasal  mucous  membrane;  sometimes  with  unnatural  dryness  of  the  nose  and 
throat. 

Kermauner  has  observed  an  abnormal  lack  of  nasal  secretion  in  those  who 
habitually  masturbate,  and  in  the  young  who  are  addicted  to  this  habit  he  recog- 
nizes a  characteristic  expression  caused  by  a  thickening  and  coarsening  of  the 
nose  and  lips  similar  to  that  produced  by  certain  diseases  of  the  hypophysis. 

The  most  striking  example  of  the  relationship  between  the  nose  and  the 
genital  organs  is  the  influence  on  dysmenorrhea  that  can  sometimes  be  ex- 
erted by  cocainizing  the  nasal  mucous  membrane.  A  few  drops  of  20  per  cent, 
cocain  solution  applied  to  the  anterior  end  of  the  lower  turbinate  and  the 
tuberculum  septi  (genital  spot)  will  often,  according  to  the  best  authorities, 
cure  severe  dysmenorrhea  and  prevent  its  recurrence  for  a  considerable  period 
of  time  (Fleisch,  Brettauer,  Meyer). 

Finally,  at  the  time  of  the  chmacteric  one  sometimes  sees  a  severe  intractable 
nasal  catarrh  associated  with  hyperesthesia  of  the  fifth  nerve.  Other  abnor- 
malitie's  mentioned  by  Kermauner,  as  occurring  at  the  change  of  life,  are  dry- 
ness and  stoppage  of  the  nose,  adenoid  and  polypoid  growths,  and  eczema  ex- 
tending from  the  outer  skin  of  the  nostrils  to  the  mucous  membrane  lining. 

BiELATIONSHIP  OF  GYNECOLOGY  TO  THE  DIGESTIVE  TRACT 

The  relationship  existing  between  the  genital  organs  and  the  digestive  tract 
is  evident  chiefly  at  the  time  of  menstruation.  Increased  activity  of  the  parotid 
glands  has  been  repeatedly  observed,  so  that  in  some  cases  one  may  speak  of  the 
condition  as  menstrual  salivation.  This  phenomenon  was  noticed  by  the 
earlier  writers,  one  of  whom  described  a  "vicarious  salivation,"  which  he  said 
might  take  the  place  of  the  normal  uterine  flow.  Habran  described  a  case  of 
periodic  swelling  of  the  parotid  gland  which  ceased  during  the  months  of  preg- 
nancy, to  be  resumed  again  after  delivery  of  the  child.  Disturbances  of  the 
mouth  during  menstruation  have  been  cited,  such  as  herpes  of  the  lips,  periodic 
toothache,  and  the  vicarious  bleeding  from  the  gums. 

Of  especial  importance  is  the  relationship  between  menstruation  and  dis- 
turbances of  the  stomach,  evidence  of  which  is  seen  both  in  functional  dis- 
turbances and  in  connection  with  organic  disease. 

The  functional  symptoms  appear  usually  in  the  premenstrual  stage  and 
last  into  the  menstrual  period,  though  sometimes  they  cease  with  the  onset 
of  the  bleeding.  The  most  common  symptoms  of  a  subjective  character  are 
loss  of  appetite,  flatulency,  nausea,  vomiting,  taste  paresthesias,  aversion  to 
certain  foods,  especially  meat,  bad  breath,  pains  in  the  stomach,  sensations  of 
hunger,  etc. 

Symptoms  of  this  kind  are  much  more  common  in  the  neurotic  and  in  those 
who  suffer  from  abnormalities  of  menstruation,  especially  dysmenorrhea. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      101 

Besides  these  minor  anomalies  of  the  stomach,  more  serious  disturbances 
may  occur.  Menstrual  and  vicarious  bleeding  from  the  gastric  mucous  mem- 
brane may  occur,  and  may  on  some  occasions  constitute  alarming  and  depleting 
hemorrhages.  In  some  cases  there  may  be  severe  cardialgia  and  symptoms 
simulating  gastric  ulcer,  the  differential  diagnosis  being  very  difficult.  In  a 
case  of  this  kind  seen  by  the  author  the  patient  had  five  abdominal  scars,  repre- 
senting as  many  operations  performed,  with  the  diagnosis  of  some  serious 
intestinal  lesion. 

The  influence  of  menstruation  is  definitely  shown  in  the  aggravation  of 
organic  lesions  of  the  stomach  during  the  monthly  period.  This  effect  is  especi- 
ally seen  in  ulcer  of  the  stomach,  which  has  a  special  disposition  to  bleed  during 
the  premenstrual  and  menstrual  periods.  Thus,  it  may  be  impossible  to  state 
whether  monthly  bleeding  from  the  stomach  is  vicarious  menstruation  without 
actual  stomach  lesion,  or  whether  the  bleeding  is  from  an  ulcer  which  bleeds 
only  when  influenced  by  menstruation. 

The  cause  of  the  influence  of  menstruation  on  the  functions  and  conditions 
of  the  digestive  tract  is  as  little  known  in  this  connection  as  it  is  in  relation  to 
other  parts  of  the  body.  Wagner  sums  up  a  discussion  of  the  matter  by  say- 
ing, "Whatever  the  cause  of  the  disturbances  may  be,  two  facts  are  indubitably 
established :  first,  the  secretory  and  motor  activity  of  the  stomach  undergoes  a 
premenstrual  and  menstrual  alteration;  and,  secondly,  that  this  leads  to  symp- 
toms according  to  the  special  disposition  of  the  individual."  Subjective  gastric 
symptoms  are  not  seen  in  all  women  at  the  time  of  menstruation,  but  they 
appear  in  a  considerable  percentage  of  them.  Those  specially  disposed  to  the 
condition  are  the  neurasthenic  and  hysteric.  Some  regard  the  dyspeptic  symp- 
toms of  these  patients  as  purely  nervous  reflexes,  while  those  who  accept  the 
internal  secretion  theory  regard  neurotic  patients  as  peculiarly  susceptible  to 
the  influences  of  altered  secretion  at  the  menstrual  period.  If  the  condition  is 
due  to  secretory  changes  the  nature  of  the  process  is  not  understood.  Accord- 
ing to  some,  it  is  the  direct  result  of  an  ovarian  hormone  circulating  in  the  body. 
It  would  seem  somewhat  more  reasonable  and  in  accordance  with  present 
physiologic  knowledge  to  suppose  that  the  stomach  changes  are  rather  due  to 
a  disturbance  of  balance  in  the  relationship  of  the  glands  of  internal  secretion 
during  menstruation,  and  that  the  direct  influence  exerted  either  on  the  nerves 
of  the  stomach  or  on  the  stomach  tissues  themselves  comes  from  some  other 
gland  than  the  ovary,  probably  the  adrenals.  Or,  still  further,  it  might  be 
assumed  that  the  gastric  symptoms  of  menstruation  may  be  the  result  of  in- 
creased general  nervous  and  emotional  irritability,  and  that  this  condition 
produces  hyperactivity  of  the  adrenal  glands  with  consequent  influences  on 
the  secretory  and  motor  apparatus  of  the  stomach.  This  theory  is  in  line  with 
the  well-known  experiments  of  Cannon,  who  has  demonstrated  the  effect  of 
the  emotions  on  the  processes  of  digestion  through  stimulation  of  the  adrenal 
glands. 


102  GYNECOLOGY 

In  addition  to  the  neurasthenic  and  hysteric,  a  predisposition  to  menstrual 
gastric  disturbances  is  seen  in  the  chlorotic  and  anemic,  and  still  more  com- 
monly in  those  who  suffer  from  congenital  or  acquired  malpositions  of  the 
stomach.  In  the  latter  class  of  cases  belong  chiefly  individuals  of  the  hypo- 
plastic type,  with  the  long  narrow  chest  walls,  splanchnoptosis,  pelvic  mis- 
placements, etc. 

Patients  with  organic  lesions  of  the  stomach  undergo  exacerbations  of  their 
symptoms  during  the  menstrual  period  in  83  per  cent,  of  cases,  according  to 
Plonies.  » 

A  form  of  menstrual  bleeding  from  the  intestinal  tract  is  that  sometimes 
seen  in  patients  suffering  from  typhoid  fever.  Still  another  instance,  and  one 
quite  frequently  seen,  is  the  increased  tendency  of  hemorrhoids  to  bleed  at  the 
time  of  menstruation. 

Diarrhea  is  not  infrequently^  an  attendant  discomfort  of  menstruation,  one 
observer  having  found  it  in  49  per  cent,  of  cases  in  a  study  of  758  women,  though 
this  figure  seems  rather  high.  Obstipation  is  another  not  uncommon  symptom. 
StiU  another  class  of  patients  frequently  seen  suffer  from  chronic  constipation 
between  the  periods,  while  during  menstruation  the  bowels  are  regular  or  even 
diarrheic. 

Certain  digestive  disturbances  often  characterize  the  menopause,  such  as 
pains  in  the  pharynx  and  esophagus,  nervous  dyspepsia  with  flatulence,  heart- 
burn, vomiting,  etc.  (Wagner). 

Diarrhea  of  a  peculiarly  obstinate  nature  sometimes  signalizes  the  begin- 
ning of  the  change  of  life  (Singer),  and  has  the  character  of  a  secretion  neurosis, 
without  sign  of  catarrhal  or  inflammatory  disease  (Wagner). 

Somewhat  more  common  is  the  occurrence  at  the  chmacteric  of  intractable 
obstipation,  with  great  tendency  to  gas  formation.  Wagner  states  that  the 
constipation  of  the  chmacteric  is  peculiarly  resistant  to  the  usual  methods  of 
treatment.     In  two  cases  he  has  had  good  results  with  ovarian  therapy. 

Hemorrhages  from  the  bowels  are  sometimes  seen  at  the  change  of  life. 
Most  of  the  bleedings  are  from  hemorrhoids,  which  at  that  time  have  a  special 
tendency  to  become  worse.  In  other  cases  where  malignant  disease  has  been 
excluded  there  has  been  demonstrated  a  true  chmacteric  intestinal  bleeding 
from  the  mucous  membrane.  It  is  possible  that  this  may  be  analogous  to  the 
bleeding  frequently  seen  from  the  vaginal  mucous  membrane  as  a  result  of  senile 
atrophy. 

The  relationship  between  the  genital  system  and  the  neighboring  organs 
of  the  digestive  tract  is  treated  in  another  section.     (See  page  141.) 

The  connection  between  pregnancy  and  the  organs  of  digestion  is  a  subject 
of  much  importance,  but  does  not  come  within  the  sphere  of  this  book. 

The  subjects  of  enteroptosis,  intestinal  bands,  and  diverticulitis  are  treated 
elsewhere. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      103 

RELATIONSHIP  O^F  GYNECOLOGY  TO  ORGANS  OF  RESPIRATION 

Lung  complications  following  gynecologic  operations  are  comparatively 
frequent.  Pulmonary  embolism  is  discussed  in  the  section  on  the  Relationship 
of  Gynecology  to  the  Circulatory  Apparatus. 

The  subject  of  postoperative  infections  of  the  lungs  forms  a  very  important 
chapter  in  surgical  convalescence.  These  infections  most  commonly  take  the 
form  of  pleurisy,  bronchitis,  and  bronchopneumonia.  Typic  lobar  pneumonia 
is  rare. 

As  in  other  local  infections  following  operation,  such  as  phlebitis  and  pyeh- 
tis,  etc.,  the  causation  of  pulmonary  inflammations  is  not  well  understood,  many 
reasons  having  been  suggested.  Patients  who  develop  pneumonia  soon  after 
a  surgical  operation  are  commonly  said  to  be  suffering  from  ''ether  pneumonia." 
It  is  probable,  as  we  shall  see,  that  ether  may  in  some  cases  be  an  exciting 
factor;  nevertheless,  that  it  is  not  the  sole  cause,  is  shown  by  the  fact  that  in- 
fections of  the  lungs  may  follow  operations  performed  under  spinal  anesthesia 
or  after  the  gas  and  oxygen  sequence. 

There  are  many  predisposing  conditions  which  undoubtedly  have  some  in- 
fluence in  producing  the  disease.  Thus,  surgical  shock  may  so  lower  the  patient's 
resistance  as  to  encourage  a  local  inflammatory  process. 

Old  age  is  very  distinctly  favorable  for  lung  infections.  In  our  own  series 
of  cases  the  incidence  of  serious  pneumonia  was  particularly  noticeable  in 
elderly  women.  The  physical  characteristics  of  the  patient  are  supposed  to 
have  some  influence,  fat,  short-necked  individuals  being  thought  to  be  es- 
pecially prone  to  pulmonary  complications.  In  our  series  this  theory  has  not 
been  borne  out. 

Bad  behavior  under  ether — i.  e.,  choking,  vomiting,  straining,  etc. — plays 
a  certain  role,  as  it  is  probable  that  such  patients  sometimes  inhale  mucus, 
sahva,  or  particles  of  food  that  may  later  act  as  foci  for  infection.  It  is  probable, 
too,  that  when  patients  act  badly  under  ether  the  necessity  of  forcing  the 'ether 
in  an  irregular  manner  serves  to  irritate  the  lungs,  and  thus  favors  either  the 
development  of  a  latent  infection  or  the  active  growth  of  newly  inhaled  bac- 
teria. That  a  certain  number  of  postoperative  lung  infections  are  proi3erly 
called  "ether  pneumonias"  is  evidenced  by  the  fact  that  they  are  much  more 
common  when  the  anesthesia  is  inexpertly  administered.  Exposure  to  -cold 
while  the  patient  is  under  anesthesia  undoubtedly  favors  lung  infections.  The 
figures  of  all  writers  on  the  subject  show  a  greater  incidence  of  the  disease  in 
the  winter  months.  There  is  no  question  that  the  inhalation  of  ether  tends  to 
stimulate  latent  foci  of  infection  into  activity,  as  is  seen  sometimes  in  the  aggra- 
vation of  a  dormant  tuberculosis  into  an  acute  form.  Administering  ether  to  a 
patient  with  a  beginning  bronchial  cold  is  very  dangerous.  Undoubtedly,  many 
cases  of  postoperative  pneumonia  are  the  result  of  stimulating  a  beginning  process 
of  infection  which  was  not  detected  in  the  preliminary  physical  examination. 


104  GYNECOLOGY 

The  nature  of  the  operation  bears  some  relation  to  pulmonary  complications. 
Pelvic  operations  are  less  commonly  followed  by  infections  of  the  lungs  than  are 
operations  performed  in  the  regions  near  the  diaphragm,  and  such  infections 
when  they  do  occur  are  apt  to  be  less  serious.  Hernia  operations  and  those 
which  require  much  handhng  of  the  gut  are  more  prone  to  lung  infection,  as 
are  cases  in  which  there  is  active  pus  or  septic  comphcations  after  operation. 

In  gynecologic  practice  laparotomies  are  ten  times  more  Hable  to  lung 
comphcations  than  are  plastic  operations  (author's  figures).  This  is  due  to 
the  fact  that  the  reflex  respiratory  irritation  from  ether  is  much  greater  dur- 
ing laparotomies  than  in  operations  on  the  body  when  the  abdomen  is  not  opened, 
excluding,  of  course,  operations  involving  the  respiratory  tract  or  nerve-centers. 

Some  of  the  pneumonias  after  operation,  especially  in  old  people,  are  of  the 
hypostatic  type. 

Still  another  important  class  are  those  which  result  from  the  lodging  of 
minute  septic  emboh  in  the  capillaries  of  the  lungs,  the  emboli  usually  starting 
from  a  local  sepsis  in  the  wound,  which  may  or  may  not  be  evident.  Doubt- 
less some  of  the  cases  which  begin  late  in  the  convalescence  are  caused  in  this 

way. 

Most  postoperative  lung  infections  do  not  get  beyond  the  stage  of  a  tem- 
porary pleurisy  or  bronchitis.  In  the  more  serious  cases  the  disease  becomes 
one  of  bronchopneumonia.     Rarely  pulmonary  abscess  or  empyema  may  develop. 

In  gynecologic  practice  the  mortality  from  postoperative  pneumonia  is  not 
very  great.  In  a  series  of  4000  consecutive  gynecologic  operations  performed 
at  the  Brookline  Free  Hospital,  reported  by  the  author  in  1910,  there  were 
2  deaths  from  pneumonia. 

During  menstruation  the  vocal  cords  undergo  a  physiologic  change  which 
results  in  slight  alterations  of  the  voice.  This  is  a  matter  of  considerable  im- 
portance to  professional  singers,  some  of  whom  are  obhged  to  refrain  from 
using  the  voice  at  the  time  of  menstruation. 

Chronic  diseases  of  the  lungs,  especially  of  tuberculous  nature,  are,  as  a 
rule,  made  worse  by  menstruation  and  pregnancy.  Menstruation  also  exerts 
an  unfavorable  influence  on  the  course  of  the  more  acute  pulmonary  infections 
of  bronchitis,  pneumonia,  and  pleurisy.  In  tuberculosis  of  the  lungs  there 
is  at  the  time  of  menstruation  a  special  tendency  to  sweating,  catarrh,  and 
headache.  The  temperature  is  apt  to  be  more  elevated  and  hemorrhages 
from  the  lungs  are  more  likely  to  occur.  Hemoptysis  at  this  time  is  often 
erroneously  regarded  as  vicarious  menstruation. 

On  the  other  hand,  chronic  lung  tuberculosis  is  often  attended  with  amenor- 
rhea, which,  as  Walthard  has  pointed  out,  is  not  necessarily  accompanied  with 
atrophy  of  the  uterus. 

In  amenorrhea  with  hypoplastic  or  atrophic  genitalia  true  vicarious  men- 
struation from  the  lungs  is  sometimes  seen. 

Acute  infections  of  the  lungs  may  metastasize  in  the  genital  organs  through 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      105 

the  circulation.  Of  the  various  infective  organisms  that  attack  the  lungs, 
the  pneumococcus  is  the  most  prone  to  cause  secondary  infections  in  the  pelvis. 
It  has  been  demonstrated  in  the  purulent  contents  of  ovarian  cysts  in  para- 
and  perimetritic  exudates  and  in  the  contents  of  pus-tubes  (Wait-hard,  Scudder). 
It  is  an  especially  common  excitant  of  peritonitis  in  children.  Genital  and 
peritoneal  tuberculosis  is  probably,  in  the  majority  of  cases,  derived  primarily 
from  old  or  latent  foci  in  the  lungs. 

Septic  processes  and  malignant  growths  of  the  pelvic  organs  may  by  entrance 
into  the  large  veins  metastasize  in  the  lungs,  as  is  seen,  for  example,  in  the 
early  involvement  of  the  lungs  of  chorio-epithelioma. 

Dyspnea,  by  interference  with  the  diaphragm,  is  the  frequent  result  of  the 
large  pelvic  tumors,  especially  those  which  have  metastasized  in  the  peritoneum 
and  those  which  are  associated  with  ascites. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  BLOOD^ 

Menstruation. — The  non-coagulability  of  menstrual  blood  has  long  been 
a  subject  of  study  and  speculation,  but  has  not  yet  been  fully  explained.  Present 
evidence  tends  to  show  that  the  phenomenon  is  not  a  part  of  a  general  phj'-sio- 
logic  change  in  the  blood,  for  the  most  recent  experiments  have  proved  that 
the  blood  in  the  general  circulation  exhibits  no  difference  in  the  time  of  clotting 
at  the  menstrual  period  (Hartmann,  Cristea,  Denk,  et  at).  It  is  now  accepted 
that  the  chemical  influence  which  prevents  coagulation  of  menstrual  blood  is 
localized  in  the  uterus,  but  just  what  the  active  substance  is  is  not  known. 
The  experiments  of  Schickele  seem  to  indicate  that  it  is  manufactured  in  the 
endometrium  under  the  stimulation  of  the  ovarian  secretions.  (See  also  page 
57.) 

Studies  of  the  blood  from  the  general  circulation  in  menstruating  women 
have  shown  certain  characteristic  changes.  During  the  premenstrual  period 
there  is  an  increase  in  the  red  corpuscular  elements  of  1,000,000  or  1,500,000, 
which  usually,  just  before  the  onset  of  the  period,  sinks  to  the  normal  leve) 
and  even  below  it.  The  hemoglobin  content  exhibits  a  periodic  rise  and 
fall,  though  not  entirely  parallel  with  the  variations  of  the  red  elements.  At 
the  beginning  of  menstruation  can  usually  be  demonstrated  a  moderate  leuko- 
cytosis which  undergoes  a  marked  fall  during  the  bleeding.  In  the  premen- 
strual period  there  is  diminished  alkalescence  of  the  blood  and  a  lower  specific 
gravity.  More  recent  investigations  (Neumann  and  Herrmann,  et  al)  have 
shown  periodic  variations  in  the  lipoid  content  of  the  blood.  Alh these  changes 
are  not  to  be  accounted  for  by  the  physiologic  loss  of  blood,  which  under  normal 
conditions  is  too  shght  to  create  so  definite  an  alteration.  They  bespeak  rather 
a  periodic  toxemia,  which  is  evidenced  not  only  by  the  blood-picture,  but  by 
marked  general  effect  on  the  physical  and  nervous  organism  (Adolf  Payer). 

^  Chief  authorities,  Adolf  Payer,  M.  Walthard. 


106  GYNECOLOGY 

The  nature  of  the  circulating  toxin,  as  is  elsewhere  frequently  mentioned, 
is  to  be  sought  either  in  an  ovarian  hormone  or  in  the  products  of  one  or  more 
other  internal  secretory  glands,  the  balance  of  whose  activity  is  disturbed  by 
the  monthly  change  in  the  function  of  the  ovaries. 

Chlorosis  is  a  disease  of  young  girlhood  occurring  at  or  soon  after  the  period 
of  puberty,  and  having  a  tendency  to  recur  later  in  life.  Although  there  is  no 
pathognomonic  blood-picture,  the  typical  case  is  characterized  by  a  marked 
decrease  in  the  hemoglobin  content  without  corresponding  diminution  in  the 
red  blood-corpuscles.  Thus,  in  a  case  of  average  severity,  the  hemoglobin  may 
register  50  to  60  per  cent.,  while  the  red  count  remains  normal.  If,  however, 
the  hemoglobin  becomes  much  reduced,  as  it  may,  to  30,  20,  or  even  10  per  cent., 
the  red  count  also  falls  very  low. 

A  special  characteristic  of  the  blood  is  its  increased  coagulability  and  its 
tendency  to  thrombosis  (Payer). 

The  relationship  between  chlorosis  and  the  genital  system  is  one  which  has 
attracted  considerable  attention.  Virchow  distinguished  a  monorrhagic  and 
an  amenorrheic  form  of  the  disease,  of  which  the  latter  is  by  far  the  more  com- 
mon. He  and  others  after  him  attempted  to  trace  a  causal  relationship  be- 
tween chlorosis  and  hypoplasia  of  the  genitals,  Virchow  regarding  the  retarded 
genital  development  as  secondary  to  hypoplasia  of  the  circulatory  apparatus. 
It  is  apparent,  however,  that  the  occurrence  of  genital  hypoplasia  in  connection 
with  chlorosis  is  not  as  common  as  formerly  supposed,  as  is  shown  by  the  fol- 
lowing figures  of  Often  (quoted  from  Opitz-Menge) : 

In  a  study  by  Otten  of  448  chlorotic  patients,  186  cases,  which  included  the  majority  of 
the  severest  cases  with  hemoglobin  under  50  per  cent.,  there  was  found  not  the  slightest  dis- 
turbance of  the  genital  functions.  Among  the  remaining  262  chlorotic  girls  and  women  were 
found  sjrmptoms  of  delayed  menarche,  oHgomenorrhea,  amenorrhea,  and  in  a  few  instances 
menorrhagia.  Dysmenorrhea  was  seen  chiefly  among  those  hving  in  wretched  surroundings. 
Some  cases  of  hypoplasia  were  seen,  but  in  such  small  numbers  that  Otten  could  draw  no  con- 
clusions as  to  an  etiologic  relationship  between  chlorosis  and  lack  of  genital  development. 

It  is  evident  that  dysmenorrhea  is  a  common  symptom  in  connection  with 
chlorosis.  A  number  of  authors  regard  chlorosis  not  as  a  primary  disease,  but 
as  secondary  to  a  beginning  or  latent  tuberculosis,  and  ascribe  many  of  the  symp- 
toms'^characteristic  of  chlorosis,  such  as  headache,  dizziness,  palpitation,  sleep- 
lessness, indigestion,  languor,  etc.,  to  the  result  of  a  tubercular  toxin  (Payer). 
It  is  probable  that  latent  tuberculosis,  though  not  being  the  sole  cause  of  chlorosis, 
should  be  regarded  as  an  important  element  in  its  etiology. 

Hemophilia  was  until  recent  times  beheved  to  be  transmitted  by  inheritance 
to  males  only,  though,  it  might  be  inherited  through  an  intermecUate  female 
ancestor  who  herself  did  not  suffer  from  the  disease.  It  is  now  known  that 
women  may  be  subject  to  the  affection,  but  not  as  commonly  as  men.  Two 
forms,  called  the  familial  and  the  sporadic,  have  been  distinguished.  In  the 
famihal  type  of  hemophiha  the  blood  is  viscous,  flows  slowly.     There  is  a  con- 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  107 

stant  diapedesis  of  leukocytes,  with  a  diminished  number  of  polynuclear  and  a 
predominance  of  mononuclear  forms. 

Clotting  is  very  slow,  lasting  from  two  and  one-half  to  nine  or  even  twelve 
hours. 

In  the  sporadic  form  the  blood  is  thin  and  watery.  The  blood-picture  is 
normal.     The  coagulation  time  is  delayed  thirty  to  fifty  minutes. 

The  disease  is  of  gynecologic  interest  chiefly  because  of  the  danger  that 
attends  puberty.  It  is  probable  that  many  of  the  severe  menorrhagias  and 
metrorrhagias  that  occur  at  puberty  have  a  hemophiUc  source.  The  condition 
is  not  always  easy  to  distinguish  from  that  of  menorrhagic  chlorosis. 

An  acquired  hemophiha  has  been  described  as  occurring  later  in  life,  but 
in  many  of  these  cases  there  has  been  a  history  of  purpura  and  morbus  macu- 
losus,  which  many  authors  regard  as  related  to  hemophiha  (Payer). 

In  the  hemophilic  there  is  no  retardation  of  the  menarche,  but  the  menstrual 
flow  when  established  is  most  profuse  and  very  resistant  to  treatment,  and 
may  sometimes  cause  the  death  of  the  patient.  Payer  quotes  the  figures  of 
Foeuckel  and  Bohn,  who  found  10  deaths  in  121  reported  cases.  No  specific 
anatomic  abnormahties  have  been  found  in  the  pelvic  organs. 

Several  cases  of  serious  or  fatal  hemorrhages  at  childbirth  have  been  re- 
ported. 

The  treatment  consists  in  trying  to  alter  the  chemical  composition  of  the 
blood  so  as  to  favor  its  clotting  or  to  apply  styptic  solutions  to  the  uterine 
cavity.  Of  the  last  named,  calcium  chlorate  (3  to  8  per  cent.)  solution  and 
adrenalin  have  been  used.  Success  has  been  gained  by  the  injection  into  the 
blood  of  10  per  cent,  gelatin  solution.  These  methods  have  in  the  latest  times 
given  way  to  transfusions  of  human  blood  or  to  the  injection  of  animal  serums, 
especially  those  prepared  from  the  horse  and  rabbit.  If  all  other  methods  fail, 
hj'sterectomy  can  be  employed  as  a  last  resort. 

Leukocytosis. — The  study  of  the  white  corpuscles  of  the  blood  is  of  great 
importance  to  the  gynecologist  in  the  detection  and  treatment  of  acute  infectious 
processes.  What  constitutes  a  hyperleukocytosis  that  may  be  regarded  as 
indicative  of  infection  is  a  matter  of  wide  difference  of  opinion,  estimates  vary- 
ing from  10,000  to  30,000.  In  our  experience  we  are  accustomed  to  consider 
a  white  count  of  15,000  as  almost  conclusive  evidence  of  infection,  while  one  of 
11,000  or  12,000  creates  a  disturbing  suspicion.  In  detecting  local  hidden 
infections  following  gynecologic  operations  the  leukocyte  count  is  most  useful, 
while  in  observing  the  course  of  an  inflammatory  process  with  special  reference 
to  surgical  intervention  the  frequent  examination  of  the  blood  and  charting  of 
the  leukocytosis  is  an  invaluable  guide,  and  one  comparable  in  importance  to 
the  curve  of  pulse  and  temperature. 

With  regard  to  the  relationship  between  inflammations  and  hyperleuko- 
cytosis infections  may  be  divided  into  three  classes:  (1)  Those  which  are  so 
mild  as  to  cause  practically  no  leukocyte  reaction;  (2)  those  which  are  so  severe 


108  GYNECOLOGY 

as  to  overwhelm  the  organism  so  that  a  leukocyte  reaction  is  prevented;  and  (3) 
a  long  hst  of  infections  between  these  two  extremes,  in  which  the  reaction  is 
present  and  proportionate  to  the  severity  of  the  disease. 

In  the  first  class  are  included  tubercular  processes  that  are  not  complicated 
with  mixed  infections  of  other  organisms;  slight  inflammations  such  as  are  seen 
in  mild  catgut  infections  are  also  counted  in  this  list.  The  second  class  com- 
prises such  conditions  as  the  sudden  overwhelming  streptococcus  peritonitis 
and  septicemia  that  on  rare  occasions  follow  abdominal  operations.  In  the 
third  class  are  included  most  of  the  septic  conditions  seen  in  gynecologic  surgery, 
such  as  appendicitis,  pyosalpinx,  wound  infections,  parametritis,  phlebitis, 
postoperative  pneumonia,  etc. 

In  the  first  part  of  an  acute  infection  there  is  a  marked  increase  in  the  polynuclear  cells, 
which  represent  the  active  agents  of  the  body  for  combatting  the  invasion  of  organisms.  The 
nmnber  of  these  cells  is  ordinarily  proportionate  to  the  severity  of  the  disease,  the  number 
of  mononuclears  and  eosinophils  being  comparatively  small.  In  order  to  follow  the  course  of 
the  infection  it  is  necessary  to  chart  the  leukocyte  count  every  twelve  or  twenty-four  hours. 
A  sudden  drop  in  the  number  of  polynuclears  indicates  a  loss  of  reactive  power  in  the  patient 
and  entails  an  unfavorable  prognosis.  A  drop  in  the  absolute  number  of  the  neutrophils, 
with  a  high  percentage  relative  to  the  mononuclears  and  eosinophils,  also  indicates  an  unfavor- 
able condition,  for  it  shows  that  the  reactive  powers  of  the  body  are  not  keeping  pace  with  the 
need  for  its  combatting  agents,  the  polynuclears.  A  cessation  of  the  leukocytosis  during  an 
acute  inflammatory  process,  followed  by  a  stationary  or  gradually  diminishing  count,  usually 
indicates  a  walling-off  and  locahzation  of  the  infection. 

If  the  contest  against  the  invading  organisms  is  successful  the  need  for  the  phagocytic 
polynuclears  is  passed,  and  they  give  way  to  the  mononuclear  Ijonphocytes,  whose  duty  is 
that  of  reparation.  An  increase  of  Ijonphocytes,  both  relatively  and  absolutely,  is,  therefore, 
characteristic  of  convalescence. 

In  the  same  way  the  eosinophils,  which  in  the  height  of  the  conflict  are  absent  or  insig- 
nificant, appear  during  the  healing  process,  "their  increase  indicating  victory  over  the  infec- 
tion." 

Posthemorrhagic  Blood-picture. — After  an  acute  hemorrhage  there  begins 
an  immediate  absorption  of  the  body  fluid  to  make  up  the  loss  in  volume  of 
the  blood  which  normally  constitutes  about  one-thirteenth  of  the  body  weight. 
This  process  is  greatly  hastened  by  the  introduction  of  physiologic  fluids  into 
the  body  by  mouth  or  rectum,  subcutaneously  or  by  intravenous  infusion. 
The  increase  in  fluid  volume  is  more  rapid  than  the  regeneration  of  the  red 
blood-corpuscles  so  that  there  is  next  a  diminution  in  the  red  cells,  each  one  of 
which  possesses  its  normal  hemoglobin  content.  Then  the  increase  in  the 
number  of  red  corpuscles  advances  more  rapidly  than  the  hemoglobin  content, 
so  that  the  next  phase  is  a  relative  deficiency  of  hemoglobin  in  the  presence 
of  a  normal  red  count  such  as  is  seen  in  chlorosis  (Walthard). 

The  viscosity  of  the  blood  is  accentuated  after  acute  hemorrhage,  and 
there  is  seen  a  hyperleukocytosis  and  an  increase  in  the  number  of  blood-plates. 

The  regeneration  of  the  blood  after  severe  loss  is  surprisingly  rapid  if  the 
hemorrhage  is  not  repeated,  as  is  frequently  seen  after  bloody  operations  or 


RELATIONSHIP  OP  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      109 

after  patients  have  had  severe  uterine  hemorrhages,  such  as  sometimes  occur 
suddenly  from  polyps,  cancer,  etc. 

Too  great  loss  of  blood  is  by  far  the  most  common  cause  of  surgical  shock. 
In  the  present  day  of  improved  operative  technic  only  the  most  difficult  of 
gynecologic  operations  should  be  attended  with  shock  as  a  result  of  loss  of 
blood.  By  the  prevention  of  the  loss  of  blood  patients  with  low  hemoglobin 
.can  be  operated  on  with  comparative  safety. 

After  chronic  loss  of  blood  from  the  genitalia  (menorrhagia  and  metrorrhagia) , 
the  appearance  of  the  blood  is  that  of  any  secondaiy  anemia,  namely,  diminu- 
tion of  red  corpuscles  and  decrease  of  the  hemoglobin  content,  poikilocytosis, 
and  absence  of  leukoc}i:osis. 

Extravasation  of  Blood. — Large  extravasations  of  blood,  such  as  are  most 
typically  seen  in  extra-uterine  pregnancy,  are  followed  at  first  by  the  char- 
acteristic posthemorrhagic  blood-picture,  described  above — i.  e.,  diminution 
in  the  number  of  red  corpuscles  and  hyperleukoc>i:osis.  If  the  hemorrhage  is 
not  repeated  the  red  cells  soon  regenerate,  but  absorption  of  the  products  of 
degenerative  changes  in  the  blood  cause  a  continuation  of  the  leukoc\i:osis  which 
may  reach  a  considerable  height  without  the  invasion  of  bacterial  organisms. 
If  the  hematocele  undergoes  thick,  fibrinous  encapsulation  as  the  long-stancUng 
non-infected  cases  often  do,  the  leukocytosis  cUsappears.  If  the  hematocele 
becomes  infected,  hyperleukocytosis  returns  and  follows  the  course  seen  in  other 
purulent  processes  (Walthard). 

The  presence  of  leukocytosis  after  blood  extravasation,  or  as  the  result  of 
absorption  from  a  degenerating  hematocele,  creates  sometimes  an  element  of 
confusion  in  making  a  differential  diagnosis  between  ectopic  pregnancy  and 
inflammatory  adnexal  disease,  being  one  of  numerous  other  signs  and  sjonptoms 
which  the  two  diseases  have  in  common. 

Necrotic  Tissue. — The  absorption  of  products  of  degeneration  in  necrotic 
tissue  is  attended  with  an  increase  in  the  leukocytes  to  15,000  and  over  (Walt- 
hard).  This  is  a  matter  of  importance,  chiefly  in  cases  of  torsion  of  ovarian 
cysts  and  necrotic  myomas.  If  infection  takes  place,  as  it  often  does  as  a  result 
of  adhesions  to  the  intestines,  the  leukocytosis  follows  the  usual  course  of 
inflammatory  processes. 

Postoperative  Leukocjrtosis. — Numerous  observers  have  described  a  hyper- 
leukocytosis following  surgical  operations,  especially  after  those  that  involve 
the  abdominal  cavity.  The  highest  point  (about  16,000  and  sometimes  over) 
is  said  to  be  reached  on  the  second  morning,  from  which  time  it  graduallj^ 
recedes  and  disappears  in  about  three  and  one-half  daj^s.  The  amount  of  the 
leukocytosis  is  dependent  to  some  extent  on  the  position,  length,  and  severity 
of  the  operation.  Many  causes  have  been  announced  to  account  for  the  phe- 
nomenon, such  as  the  loss  of  blood,  anesthesia,  opening  the  abdomen,  injuries 
from  instrumentation,  etc.  Some  regard  it  as  always  an  indication  of  sepsis 
(Zangemeister),  while  others  consider  that  ''it  represents  the  measure  of  the 


110  GYNECOLOGY 

reaction  of  the  organism  against  infection."  Apparently,  it  bears  some  rela- 
tionship to  the  postoperative  increase  in  temperature  which  it  parallels  rather 
closely. 

Jochmann  considers  it  an  indication  of  the  process  of  healing.  According  to  his  theory, 
the  leukocytes  wander  to  the  seat  of  the  wound,  where,  upon  their  disintegration,  a  proteolytic 
ferment  is  set  free.  This  ferment  is  in  part  absorbed,  but  a  part  is  used  for  the  digestion  of  the 
tissue  fragments  resulting  from  the  traiima  of  the  operation.  By  this  digestive  process  there 
are  set  free  in  the  circulation  albumoses,  which  of  themselves  are  capable  of  raising  the  body 
temperature.  In  this  way  is  very  ingeniously  and  plausibly  explained  the  parallelism  of  fever 
and  leukocytosis  after  abdominal  operations.     (Abstracted  from  Adolf  Payer.) 

SERODIAGNOSIS 

Abderhalden's  Test  for  Pregnancy  and  Cancer. — A  serodiagnostic  test  for 
the  presence  of  pregnancy  and  cancer  has  been  cUscovered  by  Emil  Abderhal- 
den,  which,  though  at  present  in  the  experimental  stage,  bids  fair  with  improve- 
ment and  simplification  of  technic  to  be  of  very  great  clinical  importance. 

The  test  is  based  on  the  assumption  that  when  a  foreign  protein  is  intro- 
duced into  the  blood  certain  protective  ferments  are  manufactured  in  the 
blood  that  are  capable  of  splitting  up  the  foreign  protein  into  peptone  or  amino- 
acids.  This  constitutes  a  form  of  digestion  which  is  termed  "parenteric  diges- 
tion," and  is  a  physiologic  process  of  great  value  in  the  bodily  economy.  The 
protective  ferments  may  be  produced  in  the  blood  in  various  ways.  Thus,  in 
the  ordinary  process  of  intestinal  digestion  the  intestinal  tract  may  be  so  over- 
loaded that  food  in  complex  form  may.  pass  into  the  circulation  and  call  forth 
digestive  ferments  in  the  blood,  which  splits  up  the  invading  proteins  into 
substances  that  are  not  harmful  to  the  organism.  The  protective  ferments 
may  be  artificially  created  in  the  blood  by  intravenous  or  intra-abdominal  injec- 
tions of  foreign  protein  material.  The  protective  ferments  are  also  manu- 
factured in  the  blood  of  an  individual  who  harbors  certain  tissues  in  the  body 
from  which  unchanged  protein  material  may  be  absorbed  in  the  circulation. 

Specific  examples  of  tissues  of  this  kind  are  the  placenta  and  cancer.  This 
makes  the  subject  of  peculiar  interest  to  the  gynecologist. 

The  principle  involved  in  this  reaction  of  the  blood  to  foreign  protein  material  is  of  vast 
importance  in  modern  scientific  medicine.  To  quote  McCord:  "The  formation  of  protective 
enzymes  then  is  sensitization,  and  all  the  phenomena  of  anaphylaxis  and  immunity  are  closely 
alhed.  In  this  phenomenon  is  the  basis  for  all  prophylactic  vaccination  and  the  foundation 
for  the  creative  activity  of  such  substances  as  tuberculin.  Although  physiologic  in  its  nature, 
the  disintegrating  of  stable  proteins  is  not  without  its  deleterious  action,  as  is  evidenced  by 
auto-intoxications.  Such  an  enzyme  cleavage  of  proteins  underUes  the  various  cutaneous 
reactions,  such  as  leprodiagnosis,  tuberculin  reaction,  and  the  cutaneous  reaction  of  syphilis. 
These  phenomena  come  as  a  result  of  introduction  and  cleavage  of  substances  of  a  kind  like 
unto  that  with  which  the  organism  is  sensitized.  Not  only  will  this  cleavage  take  place  within 
the  body,  as  in  the  instances  cited,  but  the  drawn  blood  contains  the  active  enzymes,  and  when 
placed  in  contact  with  substances  against  which  they  are  generated  structural  disrupting 
occurs  extracorporeally  with  a  breaking  down  into  simple  forms  similar  to  that  occurring 
intracorporeaUy . " 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      111 

Abderhalden  began  his  work  in  the  study  of  pregnancy.  It  has  been  known 
for  some  time,  as  demonstrated  by  Veit,  Schmorl,  and  Weichard,  that  chorionic 
vilh  are  discharged  into  the  maternal  circulation  during  the  period  of  placental 
development.  Abderhalden  showed  that  this  material,  circulating  in  the  form 
of  a  foreign  protein,  creates  specific  digestive  ferments  in  the  blood,  and  that 
when  the  mother's  blood  is  drawn  these  ferments  will  still  continue  to  act  in 
vitro  on  placental  tissue  taken  from  some  other  human  source.  In  this  way, 
therefore,  he  discovered  a  means  of  diagnosing  pregnancy. 

The  method  of  determining  the  presence  of  the  specific  protective  ferment 
is  to  bring  a  small  amount  of  serum  from  the  individual  to  be  tested  in  con- 
tact with  a  preparation  of  placental  tissue,  and  to  observe  whether  or  not  the 
serum  has  the  power  of  digesting  the  placenta. 

This  can  be  done  either  with  a  polariscope  or  by  the  method  of  dialysis,  by 
which  the  simple  products  (peptone  or  amino-acids)  into  which  the  placental 
protein  has  been  split  by  the  serum  ferments  may  be  detected  by  certain  color 
reactions. 

The  technic  of  carrying  out  the  test  is  somewhat  complicated  and  must  be 
learned  from  writers  who  are  experimenting  with  it.  The  descriptions  given  by 
Ball  are  recommended  by  the  author  as  being  especially  clear  in  detail.  Among 
other  writers  on  the  subject  are  Williams  and  Pearce,  McCord  and  Boldt. 
The  German  literature  of  the  last  two  or  three  years  is  replete  with  the  subject. 

It  may  be  said,  in  general,  that  the  placental  tissue  to  be  used  in  the  test 
is  first  prepared  by  boiling  and  coagulation,  and  then  placed  in  a  mixture  of 
chloroform  and  toluol,  in  which  it  can  be  kept  indefinitely. 

The  serum  from  the  individual  to  be  tested  is  obtained  by  venous  puncture 
and  must  be  absolutely  free  from  hemoglobin. 

The  dialysis  tubes  usually  recommended  are  the  diffusion  membranes  of 
Schleicher  and  Schull,  which  should  be  first  tested  for  their  permeability  to 
peptones.  Small  quantities  of  the  prepared  placenta  and  the  serum  from  the 
individual  to  be  tested  are  placed  together  in  the  diffusion  tube,  which  is  then 
placed  in  a  small  beaker  of  water.  The  apparatus  is  then  put  in  the  incubator 
for  twelve  to  twenty-four  hours  at  37°  C. 

If  the  patient  to  be  tested  is  pregnant  the  ferments  contained  in  the  serum 
split  up  the  protein  of  the  placental  tissue  into  peptone  or  amino-acids,  which 
permeate  the  clialysing  membrane  into  the  surrounding  water.  The  presence 
of  peptone  in  the  water  is  detected  by  adding  a  watery  solution  of  triketo- 
hydrinenhydrat  (ninhydrin),  which  gives  a  deep-blue  color  reaction.  If  the 
reaction  is  negative,  the  solution  remains  colorless  or  turns  a  slight  yellow. 

According  to  Williams  and  Pearce,  "results  as  satisfactory  as  those  by 
dialysis  are  obtained  by  mixing  tissue  and  serum  in  tubes,  and,  after  incubating 
for  twenty-four  hours,  testing  the  filtrate  on  coagulation  by  heat  and  acetic 
acid  with  ninhydrin." 

Opinions  differ  as  to  the  present  value  of  the  Abderhalden  test  for  pregnancy, 


112  GYNECOLOGY 

some  regarding  it  as  too  inaccurate  to  be  of  much  clinical  value,  while  others 
consider  it  reliable  and  practical  (McCord).  The  test  requires  much  skill  and 
care,  there  being  numerous  chances  for  error.  For  that  reason  it  has  not  yet 
come  into  general  practical  use. 

Since  Abderhalden  has  given  out  his  pregnancy  test  it  has  been  demon- 
strated that  cancer  produces  in  the  blood  a  protective  ferment  very  similar  in 
action  to  that  evoked  by  the  condition  of  pregnancy.  By  this  it  is  to  be  assumed 
that,  as  in  pregnancy,  certain  protein  material  from  the  cancerous  growth  is 
discharged  into  the  circulation,  and  causes  a  reactionary  manufacture  in  the 
blood  of  the  protective  ferment.  As  Ball  has  pointed  out,  "one  would  expect 
that  a  ferment,  if  produced  at  all,  would  be  elaborated  more  vigorously  in  a 
pathologic  process  than  would  be  necessary  in  a  purely  physiologic  one.  It 
would  also  appear  that  a  person  in  apparently  good  health  possessing  a  can- 
cerous growth  might  elaborate  a  stronger  ferment  than  a  person  far  advanced 
with  disease." 

These  conclusions  have  been  shown  to  be  true,  for  Ball  has  observed  an 
increase  in  the  density  of  the  color  reactions  in  his  cancer  cases  as  compared 
with  that  in  his  pregnancy  tests,  while  Brockman  finds  that  healthy  cancer 
patients  give  a  denser  reaction  than  do  patients  well  advanced  with  the  disease. 

The  principle  and  technic  in  making  the  test  for  cancer  are  the  same  as  for 
pregnancy,  excepting,  of  course,  that  the  tissue  to  be  tested  is  taken  from  fresh 
cancerous  material  instead  of  from  placenta. 

The  value  of  serodiagnosis  for  cancer  is  at  present  in  a  somewhat  problematic 
state,  but  it  is  probable  that  with  improvement  in  technic,  and  with  increased 
knowledge  of  the  principles  of  the  reaction,  the  test  will  in  time  prove  to  be  of 
great  general  benefit. 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE  ORGANS  OF  CIRCULATION 

Certain  differences  in  the  organs  of  circulation  between  the  sexes  are  to  be 
noted. 

The  heart  and  blood-vessels  of  woman  are  both  relatively  and  absolutely 
smaller  and  weaker  than  in  man.  The  heart  is  smaller  and  weighs  less  at  a 
given  age.  Thus,  according  to  the  figures  of  Miiller,  the  average  of  weight 
of  the  female  heart  between  the  ages  of  thirty  and  forty  is  234.7  gm.,  as  against 
297.4  gm.  for  the  male.  It  has  been  demonstrated  (Kani)  that  the  (lifference 
in  the  blood-vessels  between  the  sexes  is  due  to  a  greater  thickness  of  the  media 
in  the  vessel  wall  in  man,  a  point  which  Jaschke  thinks  may  be  shown  to  have 
important  clinical  significance. 

In  woman  there  is  a  more  frequent  high  bifurcation  of  the  aorta,  while  the 
apex  of  the  heart  is  relatively  higher,  due  to  the  shorter  thorax  and  to  the  smaller 
size  of  the  heart.  Physiologically,  the  pulse-rate  in  woman  averages  higher 
and  the  fluctuations  are  greater. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      113 

A  special  female  characteristic  is  marked  vasomotor  excitability  resulting 
from  the  emotions,  which  may  be  so  great  as  to  produce  uterine  bleeding,  a 
phenomenon  of  familiar  occurrence.  This  vasomotor  sensitiveness  has  an  im- 
portant bearing  in  a  vast  number  of  ways,  both  in  the  physiologic  and  patho- 
logic sphere  of  woman. 

The  blood-pressure  in  woman  is  relatively  lower  than  in  man,  and  is  sub- 
ject to  greater  fluctuations,  as  a  result  of  the  greater  lability  of  the  pulse  and 
of  variations  referable  to  vasomotor  and  psychic  excitability. 

THE   HEART 

At  puberty  the  heart  becomes  markedly  increased  in  size.  With  the  estab- 
Ushment  of  the  menses  are  often  seen  in  girls  functional  irregularities  of  the 
heart,  which  may  in  some  cases  be  of  a  more  or  less  serious  nature.  Most 
commonly  they  consist  of  palpitation  and  vasomotor  manifestations,  such  as 
blushing,  blanching,  faintness,  fluttering  of  the  eyelids,  etc.  In  severe  cases 
the  frequency  of  the  pulse  may  be  very  marked  and  attended  with  pain  in  the 
region  of  the  heart,  shortness  of  breath,  feeling  of  oppression  and  rapid  breath- 
ing, symptoms  which  disappear  after  the  onset  of  the  blood,  to  reappear  at  the 
following  periods  with  diminished  severity.  In  these  cases  heart  lesions  or 
changes  in  the  size  or  tone  of  the  heart  cannot  be  detected. 

Circulatory  disturbances  at  puberty  are  seen  most  frequently  in  individuals 
who  have  a  neurotic  inheritance  and  in  those  whose  early  environment  has 
predisposed  them  to  an  unstable  nervous  equihbrium.  In  some,  indications 
of  enlarged  thyroid  and  hyperthyroidism  can  be  seen.  Chlorosis,  anemia,  and 
the  various  hypoplasias  are  conditions  especially  apt  to  be  attended  with  heart 
symptoms  at  puberty. 

Sometimes  the  above-mentioned  symptoms  continue  to  recur  at  the  men- 
strual periods,  especially  if  there  is  dysmenorrhea.  Jaschke  describes  a  type  of 
case  in  which  the  heart  symptoms  alternate  with  those  of  menstrual  pain,  and 
applies  the  term  "vicarious  dysmenorrhea"  to  the  condition. 

Other  conditions  that  predispose  to  functional  cardiac  anomalies  at  the 
menses  are  hyperthyroidism  and  pelvic  diseases,  especially  those  attended  with 
menorrhagia.  In  young  women  with  amenorrhea,  heart  murmurs  can  often 
be  demonstrated  periodically,  only  to  disappear  after  the  return  of  the  menses 
(Jaschke). 

During  cohabitation  subjective  heart  symptoms  may  appear,  and  if  organic 
lesions  be  present  the  symptoms  may  be  alarming.  Kirsch  calls  attention  to 
the  injury  to  the  functions  of  the  heart  resulting  from  long-continued  incomplete 
orgasm,  such  as  is  caused  by  impotence  of  the  husband,  precocious  ejaculation, 
coitus  interruptus,  and  the  use  of  condoms  and  vaginal  preventives  to  concep- 
tion. The  heart  symptoms  from  this  cause  (tachycardia,  heart  weakness, 
dizziness,  etc.)  are  only  partial  evidences  of  a  general  nervous  weakness,  which 

8 


114  GYNECOLOGY 

is  manifested  elsewhere  by  backache,  pelvic  pressure  pains  in  the  legs,  and 
numerous  other  symptoms,  all  due  to  the  same  cause. 

Increased  functional  irritability  of  the  heart  is  observed  at  the  chmacteric. 
At  this  period  of  life  appear  also  special  characteristic  vasomotor  symptoms, 
the  well-known  "Ausfallserscheinungen."  These  consist  chiefly  of  hot  flushes 
or  sensations  of  heat  which  appear  momentarily.  They  are  dealt  with  more 
fully  elsewhere.     (See  Climacteric.) 

Schickele  believes  that  the  vasomotor  disturbances  of  the  change  of  hfe 
are  due  to  a  rise  in  blood-pressure  consequent  upon  the  absence  of  the  ovarian 
secretion  which  normally  acts  as  a  blood  depressant.  This  theory  has  not 
been  entirely  substantiated. 

It  should  be  said  that  functional  cardiac  manifestations  seen  in  relation  to 
pelvic  changes,  especially  those  of  the  critical  periods  (menarche,  menstrua- 
tion, pregnancy,  and  the  menopause),  are  by  no  means  constant,  but  are  princi- 
pally seen  in  individuals  of  a  neurasthenic  or  hysteric  temperament. 

Long-continued  bleeding  from  pelvic  disease  may  cause  anatomic  changes 
in  the  heart  muscle,  a  condition  sometimes  referred  to  as  "the  anemic  heart" 
(Walthard).  There  is  seen  a  fat  deposit  in  the  protoplasm  of  the  cells  of  the 
heart  muscle,  an  appearance  not  to  be  distinguished  from  true  fatty  degenera- 
tion. The  condition  has  been  shown  experimentally  to  be  the  result  of  incom- 
plete oxidation.  At  the  same  time  there  takes  place  a  dilatation  of  the  heart, 
which,  however,  is  not  permanent,  disappearing  as  it  does  after  cessation  of  the 
uterine  bleeding  and  restoration  of  the  blood  to  its  normal  constituency.  The 
therapy  of  the  anemic  heart  resulting  from  pelvic  disease  is,  therefore,  identical 
with  that  of  the  pelvic  disease. 

Pelvic  diseases  that  are  attended  with  long-continued  disturbances  of 
nutrition  and  respiration,  like  large  ovarian  cysts,  myomata,  and  tumors 
associated  with  ascites,  lead  to  brown  atrophy  of  the  cells  of  the  heart 
muscles,  a  condition  seen  at  autopsy  in  cases  where  there  has  been  cachexia 
and  marasmus. 

The  relationship  between  the  genitalia  and  organic  lesions  of  the  heart  is 
not  a  particularly  definite  one,  there  being  very  little  causal  connection  between 
diseases  of  the  two  systems.  In  uncompensated  valvular  heart  disease  with 
edema  and  ascites  the  labia  majora  may  become  swollen  and  edematous.  It 
is  observed  also  that  long-standing  uncompensation  may  be  attended  with 
edema  and  hypertrophy  of  the  uterine  mucosa,  leading  to  menorrhagia  and 
metrorrhagia,  though  in  the  hght  of  recent  research  this  explanation  of  the 
bleeding  must  be  accepted  with  reserve. 

A  rare  result  of  heart  disease,  mentioned  by  Jaschke,  is  an  excessive  bleeding 
from  a  corpus  luteum  from  which  it  is  claimed  there  may  ensue  an  adhesive 
peritonitis.  There  is  no  doubt  that  under  normal  conditions  considerable  blood 
is  not  infrequently  shed  from  the  corpus  luteum.  Under  the  influence  of  the 
chronic  passive  congestion  of  heart  disease  it  is  reasonable  to  believe  that  such 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  115 

a  hemorrhage  may  be  much  greater  than  that  which  takes  place  under  physio- 
logic conditions. 

The  secondary  anemia  from  bleeding  fibroids  and  other  tumors,  which  is 
manifested  by  a  temporary  compensatory  enlargement  of  the  heart,  leads  also 
to  changes  in  the  walls  of  the  veins  which  predispose  to  thrombus  formation. 
Infection  of  the  thrombus  may  take  place,  with  the  sending  off  of  septic  emboh 
into  the  circulation. 

Myoma  Heart. — Of  particular  interest  to  the  gynecologist  is  the  so-called 
"myoma  heart."  The  frequency  with  which  functional  and  sometimes  organic 
changes  in  the  heart  are  associated  with  uterine  fibroids  has  in  times  "past  led 
to  the  belief  that  there  exists  a  definite  immediate  causal  relationship  between 
the  two  conditions.  Just  how  the  heart  lesions  are  produced  was  not  clearly 
explained.  Some  have  believed  that  fibroid  tumors  manufacture  a  toxin  which 
in  circulating  through  the  blood  exerts  a  deleterious  influence  on  the  heart. 
Neu  advanced  the  interesting  theory  that  the  changes  in  the  heart  are  secondary 
to  hypertrophy  of  the  thyroid  gland,  which  of  itself  is  in  some  way  induced  by 
the  myomatous  growth.  Thus  the  cardiac  symptoms  by  this  theory  are  in 
reality  manifestations  of  hyperthyroidism.  The  general  tendency  at  present  is 
to  ignore  any  causal  relationship  between  the  heart  disturbance  and  fibroid 
growth,  excepting  in  cases  of  long-continued  bleeding  in  which  compensatory 
changes  are  seen  in  the  heart,  such  as  are  mentioned  above  in  describing  the 
anemic  heart — changes  that  would  appear  in  a  secondary  anemia  from  bleed- 
ing in  any  other  part  of  the  body. 

Certain  vasomotor  symptoms  are  sometimes  observed  in  women  who  have 
fibroids,  such  as  tremors,  hot  flushes,  dizziness,  tachycardia,  etc.,  which  have 
seemed  to  substantiate  the  claim  of  the  toxic  influence  of  fibroid  tumors.  These 
symptoms,  however,  are  frequent  in  women  without  fibroids,  and  occasionally 
appear  for  the  first  time  after  hysterectomy  for  fibroids,  so  that  they  are  not 
valuable  evidence  in  support  of  the  claim.  Notwithstanding  the  present  trend 
to  disassociate  myomata  from  heart  lesions  and  to  discard  the  toxic  theory 
of  uncomphcated  fibroids,  it  is  well  to  reserve  judgment  until  the  facts  are 
"better  established.  The  profound  effect  which  fibroids  without  local  symptoms 
often  have  on  the  general  organism  of  woman,  and  especially  on  her  nervous 
system,  certainly  suggest  that  the  older  theories  may  not  be  without  basis. 

THE  BLOOD-VESSELS 

Arteriosclerosis  as  the  result  of  infectious  diseases,  especially  of  syphiHs, 
may  occur  in  young  women  and  be  the  exciting  cause  of  menorrhagia  and 
metrorrhagia.  Non-infectious  arteriosclerosis  has  in  times  past  been  supposed 
to  play  a  very  important  role  in  the  causation  of  uterine  hemorrhages.  In  its 
general  aspects  arteriosclerosis  is  less  common  in  women  than  it  is  in  men,  but 
it  has  been  shown  that  the  vessels  of  the  female  genital  organs,  and  especially 


116  GYNECOLOGY 

of  the  uterus,  possess  a  special  predisposition  to  become  sclerotic.  This  has  been 
demonstrated  both  in  those  who  have  had  frequently  repeated  pregnancies,  a 
long-recognized  cause  for  arteriosclerosis,  but  also  in  the  nulliparous.  Pankow 
states  that  he  can  distinguish  special  forms  of  local  sclerosis,  due  to  child-bearing 
and  to  menstruation  in  virgins,  and  speaks  of  pregnancy-sclerosis  and  men- 
struation-sclerosis. A  special  preclimacteric  arteriosclerosis  has  been  shown 
to  be  a  not  uncommon  cause  of  premature  thickening  of  the  vessels,  especially 
if  there  be  added  the  effect  of  frequent  child-bearing. 

In  the  unmanageable  uterine  bleeding,  so  often  seen  in  women  near  the 
menopause  without  demonstrable  anatomic  abnormality,  arteriosclerosis  has 
been  widely  accepted  as  a  most  important  cause,  but  more  recent  investiga- 
tions tend  to  prove  that  its  influence  in  this  condition  has  been  very  greatly 
exaggerated.  The  present  trend  is  in  favor  of  irregularities  in  the  function  of 
the  ovaries  as  the  chief  etiologic  factor. 

Thrombophlebitis. — Phlebitis  is  a  matter  of  interest  to  the  gynecologist, 
in  that  it  constitutes  a  somewhat  frequent  and  troublesome  complication  in  the 
convalescence  of  pelvic  operations. 

The  form  of  phlebitis  most  commonly  seen  in  the  practice  of  gynecologic 
surgery  is  of  the  so-called  septic  non-pyogenic  type,  and  is  the  result  of  attenu- 
ated or  non-virulent  organisms  circulating  in  the  blood  and  lodging  in  the 
inner  coat  of  a  vein,  usually  of  the  lower  extremity.  The  introduction  of  the 
organism  into  the  circulation  can  probably  take  place  at  the  time  of  the  opera- 
tion, or  it  may  be  the  result  of  a  mild  unrecognizable  sepsis  at  the  seat  of  opera- 
tion. The  offending  germ  after  lodging  in  the  intima  of  the  vein  causes  a  lesion 
of  the  membrane  which  results  in  a  thrombus  and  a  local  inflammatory  process, 
though  just  how  this  process  comes  about  is  not  definitely  known. 

McLean  regards  as  an  important  cause  of  thrombosis  the  necrosis  of  tissue 
remnants  at  the  seat  of  operation,  which  harbor  a  low  grade  of  infection  and 
send  off  toxins  into  the  circulation  favorable  for  the  development  of  a  thrombus. 
This  theory  seems  a  very  reasonable  one,  for  thrombosis  is  especially  apt  to  follow 
operations  where  there  is  much  tying  of  pedicles  and  leaving  of  ragged  shreds 
of  tissue. 

Extension  of  the  thrombus,  lymphangitis,  and  edema  cause  a  swelling  of  the 
leg  which  varies  greatly  in  amount  in  different  cases.  There  is  always  pain,  and 
if  the  swelling  is  considerable  the  surface  becomes  white  and  shining,  a  condi- 
tion to  which  the  name  "phlegmasia  alba  dolens"  was  given  in  ancient  times. 

In  by  far  the  greater  number  of  cases  the  disease  starts  in  the  veins  of  the 
lower  leg,  the  first  evidence  of  trouble  being  a  sharp  cramp-like  pain  in  the  calf. 
In  most  cases  it  extends  upward  along  the  internal  saphenous  vein,  causing  pain 
and  tenderness  along  the  inner  side  of  the  thigh.  In  more  serious  but  less  fre- 
quent cases  the  inflammatory  process  of  the  vein  may  extend  past  the  femoral 
ring  into  the  veins  of  the  pelvis,  or  it  may  originate  in  the  femoral  or  iliac  veins. 
Postoperative  phlebitis  usually  appears  between  the  eighth  and  twenty-first 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  117 

day  of  convalescence,  though  it  sometimes  does  not  make  itself  evident  until 
several  weeks  later.  The  course  of  the  disease  varies  within  wide  limits,  the 
mildest  cases  lasting  only  a  few  days,  with  no  after-effects,  and  the  more  severe 
cases  lasting  weeks,  and  often  resulting  in  permanent  enlargement  and  partial 
disability  of  the  leg. 

Thayer  found,  in  an  examination  of  a  number  of  cases  of  postoperative 
thrombosis  several  years  after  the  operation,  that  when  the  iliac  and  femoral 
veins  were  involved  there  was  usually  a  permanent  enlargement  of  the  leg. 
Schenck  estimated  that  about  65  per  cent,  of  patients  with  postoperative 
phlebitis  never  completely  recover,  and  that  if  recovery  is  to  take  place  it  will 
come  within  the  first  year. 

Phlebitis  is  practically  always  attended  with  moderate  rise  of  temperature, 
which  often  appears  several  days  before  the  onset  of  subjective  symptoms. 

Postoperative  phlebitis  of  the  non-pyogenic  type  should  always  be  regarded 
as  a  serious  affection,  the  chief  danger  being  the  possibility  of  a  separation  of 
an  embolic  clot  from  the  thrombus.  This  danger  is  present  in  cases  of  the 
mildest  forms,  and  is  to  be  considered  for  several  weeks  after  the  patient's 
apparent  recovery.  Numerous  cases  of  pulmonary  embolism  have  been  re- 
ported in  consequence  of  the  apphcation  of  massage  to  relieve  the  pain  of 
phlebitis.  Nurses  should  always  be  given  strict  instructions  concerning  the 
nature  and  position  of  pain  in  phlebitis.  This  is  particularly  important  be- 
cause the  initial  symptoms  are  usually  regarded  by  the  patient  as  those  of 
muscular  cramp. 

Another  danger  to  which  a  patient  with  phlebitis  is  subject  is  the  possibility 
of  the  disease  changing  from  non-pyogenic  to  the  pyogenic  type. 

Pyogenic  phlebitis  usually  starts  as  such,  and  represents  the  infection  of 
a  more  virulent  organism  than  does  the  preceding  form.  Whereas  non-pyogenic 
phlebitis  often  follows  what  may  be  called  "clean"  operations,  the  pyogenic 
type,  as  a  rule,  is  preceded  either  by  an  operation  for  some  purulent  condition 
or  by  postoperative  active  sepsis  at  the  seat  of  the  operation,  such  as  stitch- 
abscess  of  the  wound,  septic  parametritis,  etc.  The  course  of  pyogenic  phlebitis 
is  a  severe  and  alarming  local  sepsis  about  the  affected  part  of  the  vein  with 
marked  constitutional  reaction.  Pyogenic  phlebitis  following  gynecologic  opera- 
tions usually  appears  in  the  leg  and  tends  to  remain  localized.  It  may,  how- 
ever, become  diffuse,  enter  the  circulation,  and  cause  a  fatal  septicemia,  or  it 
may  send  septic  emboli  to  distant  parts  of  the  body,  causing  pyemic  abscesses. 

Treatment. — The  preventive  treatment  of  postoperative  phlebitis  is  un- 
remitting attention  to  surgical  asepsis,  but,  even  with  the  greatest  precautions 
and  with  apparently  perfect  healing  of  wounds,  phlebitis  occasionally  appears. 

If  we  accept  the  theory  of  McLean,  that  thrombophlebitis  is  the  result  of 
necrotic  tissue  remnants,  it  is  evident  that  clean,  skilful  surgical  technic  with 
considerate  handling  of  tissues  is  of  the  greatest  importance  in  preventing  the 
complication. 


118  GYNECOLOGY 

Treatment  of  the  non-pyogenic  cases  consists  in  complete  rest  in  bed  with 
elevation  and  immobility  of  the  leg.  Comfort  is  given  by  applying  an  im- 
mense cotton  swathing  to  the  leg,  surrounded  by  hot-water  bags.  Local  medical 
applications  to  the  leg  are  of  no  great  curative  value,  but  relief  to  the  pain  is 
sometimes  afforded  by  painting  the  leg  with  ichthyol  or  by  applying  com- 
presses soaked  in  a  weak  lead-and-opium  lotion.  Matas  recommends  kaoUn 
poultices. 

The  treatment  of  purulent  phlebitis  is  usually  surgical,  and  consists  either 
in  incision  and  drainage  or,  in  some  cases,  if  the  disease  is  sufficiently  localized, 
in  excision  of  the  infected  area  with  ligation  of  the  vein  above. 

Embolism. — The  subject  of  embolism  is  also  of  particular  interest  to  the 
gynecologist  in  view  of  the  fact  that  fatal  embolism  is  peculiarly  common  after 
pelvic  operations,  especially  those  which  implicate  the  hemorrhoidal  and 
pampiniform  plexus  of  veins  and  those  which  involve  the  appendix.  In  opera- 
tions for  strangulated  hernia  there  is  said  to  be  especial  danger  of  emboHsm, 
due,  according  to  Gussenbauer,  to  the  fact  that  the  thrombi  are  formed  in  the 
veins  of  the  strangulated  loop  and  set  free  in  the  circulation  when  the  obstruc- 
tion is  released. 

In  nearly  all  statistics  fatal  embolism  after  hysterectomy  for  fibroids  plays 
a  somewhat  conspicuous  part.  In  our  experience  the  accident  has  happened 
most  frequently  after  minor  pelvic  operations  during  which  the  appendix  was 
removed  as  a  routine  procedure. 

Postoperative  emboli  occur  most  frequently  in  the  lungs,  other  less  com- 
mon places  being  the  kidney,  spleen,  brain,  and  pleura. 

The  cause  of  surgical  embolism  cannot  always  be  traced.  Thrombophle- 
bitis, especiallj^  of  the  pelvic  veins,  with  release  of  a  small  blood-clot  into  the 
circulation,  is  probably  often  the  underlying  cause,  especially  in  those  cases 
in  which  the  embolism  takes  place  at  a  considerable  time  after  the  operation. 

Undoubtedly,  the  manner  of  ligaturing  the  pelvic  veins  is  of  very  great 
importance,  a  clean,  skilful,  and  bloodless  technic  probably  being  the  best  pro- 
phylactic against  the  accident. 

Pulmonary  embolism  may  occur  during  the  operation,  a  short  time  after  it, 
or  at  any  time  during  the  convalescence,  often  not  until  the  patient  is  up  and 
about. 

If  the  embolus  is  a  large  one,  death  may  be  instantaneous.  Usually  the 
patient  does  not  die  until  several  minutes  after  the  first  symptoms,  which 
consist  of  sudden  pain  in  the  chest,  difficulty  of  breathing,  rapid  pulse,  deep 
livid  color  of  the  face,  faintness  and  premonition  of  death,  with  rapid  loss  of 
consciousness.  Pulmonary  emboli  are  not  always  fatal.  A  small  aseptic  em- 
bolus may  cause  only  a  sharp  pain,  with  a  temporary  distress  in  breathing  and 
fleeting  cyanosis,  all  symptoms  disappearing  in  a  few  moments  not  to  return, 
with  the  possible  exception  of  slight  lingering  pain  in  the  chest. 

Small  non-fatal  emboU  may  result  in  a  hemorrhagic  infarct  of  the   lungs. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  119 

causing  a  moderate  elevation  of  temperature  for  several  days,  with  signs  in 
the  chest  of  localized  consolidation  and  serofibrinous  pleurisy.  The  infarct 
may  be  sufficient  to  cause  hemoptysis. 

If  the  embolus  is  discharged  from  a  septic  thrombus,  the  lodgment  in  the 
lung  may  result  in  a  serious  pulmonary  abscess. 

Varicose  Veins  (Varices,  Phlebectasis) . — Varicose  veins  relate  to  a  condition 
of  permanent  dilatation  due  to  changes  in  the  vessel  walls.  The  term  "varicose 
veins"  is  most  commonly  applied  to  the  varices  which  occur  in  the  lower  limbs. 
These  are  far  more  common  in  women  than  in  men,  a  result  of  the  special 
obstructing  influence  exerted  by  the  pregnant  uterus  on  the  veins.  The  venous 
enlargement  usually  takes  place  in  the  superficial  veins,  sometimes  in  the 
deeper  vessels.  In  a  third  of  the  cases  due  to  pregnancy  the  affection  is 
bilateral,  according  to  Jaschke,  and  when  unilateral  or  more  marked  on  one 
side  than  the  other  the  veins  of  the  right  leg  suffer  more,  probably  on  account 
of  the  tendency  of  the  gravid  uterus  to  rest  in  the  right  side  of  the  pelvis.  As 
a  rule,  the  varices  of  pregnancy  disappear  after  delivery  of  the  child,  but  the 
stretching  of  the  veins  predisposes  them  to  greater  danger  of  thrombosis, 
phlebitis,  and,  later,  permanent  varicosities  (Jaschke). 

Varicose  veins  of  the  leg  of  long  duration  are  on  account  of  their  exposed 
position  especially  subject  to  trauma,  with  consequent  rupture  or  septic  throm- 
bophlebitis. On  account  of  the  incompetent  circulation,  lesions  of  the  veins 
do  not  heal  readily  and  indolent  ulcers  very  frequently  result.  If  the  ulcers 
are  neglected  the  surrounding  tissues  undergo  a  change,  due  chiefly  to  involve- 
ment of  the  lymphatics,  and  become  thickened,  brawny,  and  insensible,  a  con- 
dition resembling  elephantiasis. 

Varicose  veins  of  the  legs,  with  their  various  complications,  are  so  common 
in  women  that  the  affection  may  well  be  included  in  the  hst  of  gynecologic 
diseases. 

Varicosities  of  the  veins  of  the  vagina  and  vulva,  though  less  common  than 
those  of  the  lower  extremities,  are  by  no  means  infrequent  as  a  complication  of 
pregnancy,  and  are  a  source  of  serious  clanger  from  rupture  as  a  result  of  trauma, 
especially  that  from  coitus  or  childbirth.  Fatal  hemorrhages  from  this  cause 
have  been  reported.     The  condition  is  discussed  in  greater  detail  on  page  293. 

Varicosities  in  the  vaginal  plexus  of  veins  lead  at  delivery  to  separation  of 
the  vaginal  mucous  membrane  from  the  paravaginal  tissue,  and  hence  predis- 
pose to  later  prolapse  (Jaschke). 

A  most  important  phase  of  varix  formation  is  that  which  takes  place  in  the 
pampiniform  plexus  of  veins  in  the  broad  ligament  in  conditions  of  chronic 
pelvic  congestion,  especially  when  due  to  malpositions  of  the  uterus.  Accord- 
ing to  Opitz,  and  in  this  our  own  experience  coincides,  many  of  the  pelvic  pains 
that  attend  uterine  displacements  are  due  to  varicose  veins  in  the  broad  liga- 
ments. These  varicosities  are  often  so  tender  as  to  cause  a  mistaken  diagnosis 
of  inflammatory  adnexal  disease.     Restoration  of  the  uterus  to  its  normal  posi- 


120  GYNECOLOGY 

tion  will  often,  though  not  always,  cause  the  venous  engorgement  to  disappear 
with  complete  relief  of  symptoms. 

The  pelvic  veins  may  become  varicose  from  pregnancy  or  from  large  tumors, 
and  Jaschke  has  reported  fatal  intra-abdominal  hemorrhages  as  a  result  of  this 
condition. 

Other  phlebectases  occurring  as  the  result  of  pregnancy  are  seen  in  rare 
instances  in  relation  to  the  uterine  cervix  and  body,  to  the  bladder,  rectum,  and 
stomach  (Kaufmann,  Halban,  Bachrach,  Ewald,  Preiss). 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE  NERVOUS  SYSTEM^ 

Influence  of  Menstruation  on  the  Nervous  System. — In  considering  the 
relationship  between  the  genital  and  nervous  systems  one  naturally  regards 
first  the  important  influence  which  the  function  of  menstruation  has  on  the 
general  organism  of  a  woman. 

John  Goodman,  in  1878,  in  an  essay  entitled  "The  Cyclical  Theory  of  Men- 
struation," was  one  of  the  first  to  call  attention  to  the  fact  that  the  function  of 
menstruation  is  not  a  purely  local  process,  but  the  expression  of  a  profound 
change  in  the  general  circulatory  system.  This  periodic  change  in  the  circula- 
tion Goodman  regarded  as  under  the  direction  of  the  nervous  system  and  as 
following  a  regular  law  of  rhythmic  rest  and  activity,  such  as  is  represented  by 
the  heart  action. 

Mary  Putnam  Jacobi,  in  the  Boylston  prize  essay  of  Harvard  University  for 
1876,  presented,  under  the  title  of  "The  Question  of  Rest  for  Women  during 
Menstruation,"  a  most  valuable  contribution  to  the  physiology  of  the  pelvic 
organs,  by  expounding  for  the  first  time  the  ivave  theory  of  menstruation. 

According  to  this  theory,  menstrual  blood  represents  the  overflow  of 
superfluous  nourishment  material  which  has  been  stored  up  as  a  provision  for 
impregnation,  but  which  when  impregnation  does  not  take  place  is  discharged 
in  the  form  of  a  catamenial  flow. 

Jacobi  saw  in  this  a  rhythmic  wave  in  the  metabohc  processes  of  woman 
which  reaches  its  maximum  immediately  before  and  its  minimum  immediately 
after  menstruation.  In  order  to  prove  her  theory,  Jacobi  made  monthly  obser- 
vations on  several  women  and  estabhshed  that  just  before  the  menstrual  period 
there  is  an  increase  in  the  body  temperature,  in  the  blood-pressure,  in  muscle 
strength,  and  in  the  pulse-beat,  all  of  which  gradually  diminish  during  the 
menstrual  period  and  are  at  their  lowest  ebb  at  its  close. 

These  observations  were  confirmed  by  other  investigators.  In  1890  von 
Ott  and  his  pupil  Schicharell  studied  in  57  normal  women  through  68  menstrual 
periods  the  temperature,  pulse,  blood-pressure,  muscle  strength,  hmg  capacity, 
inspiration  and  expiration  strength,  and  the  ocular  reflexes,  and  from  these 
studies  concluded  that  the  energy  of  the  functions  of  the  female  organism  is  at  its 

^  Some  of  the  material  in  this  section  is  taken  from  an  article  by  the  author,  published  in  the 
Boston  Medical  and  Surgical  Journal,  1913. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM 


121 


height  immediately  before  menstruation  and  that  it  diminishes  from  the  time  of 
the  beginning  of  the  flow  of  blood.  Von  Ott  constructed  a  curve  which  represents 
graphically  the  monthly  wave  of  the  life  processes  of  normal  woman  (Fig.  22). 
The  discussion  as  to  the  physiologic  cause  of  this  menstrual  wave  of  depres- 
sion, whether  it  is  the  result  of  an  ovarian  internal  secretion,  whether  it  is  from 
a  rhythmic  change  in  the  central  nervous  system,  or  what  not,  is  not  at  present 
conclusively  established.  The  curve  of  Ott  shows  plainly  that  there  is  in  the 
organism  of  the  healthiest  woman  a  monthly  period  of  depression  in  her  vital 
processes  which  finds  definite  expression  in  all  her  activities.  This  fact  is  of  the 
very  greatest  importance  in  our  understanding  of  a  woman,  either  as  an  indi- 
vidual or  as  a  patient.  As  Havelock  Ellis  has  pointed  out,  the  chart  of  von  Ott 
would  probably  be  paralleled,  if  it  were  possible  to  make  accurate  observations, 
in  all  the  senses,  emotions,  and  intellectual  activities  of  women. 


100 


Menstructtx-OTL 


Fig.  22. — Curve  of  von  Ott. 


In  the  preceding  sections  on  the  relationship  of  gynecology  to  the  general 
organism  we  have  seen  that  during  menstruation  the  most  varied  disturbances 
take  place  in  nearly  every  part  of  the  body — i.  e.,  in  the  organs  of  sense,  in  the 
digestive  tract,  in  the  skin,  in  the  circulatory  apparatus,  etc.  In  the  psychic 
and  nervous  organization  of  perfectly  healthy  women  the  menstrual  curve  is 
very  plainly  manifested.  There  is  at  that  time  a  greater  sensitiveness  and  im- 
pressionability. The  individual  is  far  more  irritable  and  subject  to  outbursts 
of  ill-temper  and  to  unreasonable  caprices.  There  is  markedly  less  self-control 
and  an  invariable  tendency  to  depression.  The  nervous  refiexes  are  impaired 
and  women  are  less  skilful  and  dextrous  during  the  menstrual  period. 

What  we  have  said  so  far  relates  to  women  in  perfect  health.     Under  patho- 


122  GYNECOLOGY 

logic  conditions  the  same  upward  and  downward  curve  occurs,  but  the  changes 
may  be  much  more  marked. 

In  considering  the  pathologic  aspects  of  the  relationship  between  menstrua- 
tion and  nervous  disorders  we  must  view  the  subject  in  two  aspects. 

First,  neuroses  that  are  dependent  entirely  on  an  abnormal  menstrual  func- 
tion.    In  this  case  cure  of  the  menstrual  difficulty  results  in  cure  of  the  neuroses. 

Second,  abnormalities  of  the  nervous  system  which  are  made  worse  by  the 
menstrual  function.  In  this  case,  cure  of  a  menstrual  irregularity  or  arresting 
of  menstruation  is  a  source  of  relief,  though  not  necessarily  a  cure,  to  the  nervous 
abnormality. 

(1)  Neuroses  as  a  Result  of  Menstrual  Irregularities.— Oi  the  menstrual 
irregularities,  that  may  produce  neuroses,  dysmenorrhea  is  by  far  the  most  im- 
portant. By  the  term  "dysmenorrhea"  is  meant  the  so-called  essential  dys- 
menorrhea, which  consists  of  cramp-like  pains  of  the  uterus,  felt  usually  in  the 
front  of  the  lower  abdomen,  occasionally  in  the  sacral  region.  The  pains  of 
pelvic  inflammation,  chronic  appendicitis,  or  other  abdominal  disease  that 
are  exaggerated  during  menstruation  are  not  included  under  the  term  "essential 
dysmenorrhea"  {q.  v.).  Essential  dysmenorrhea  is  undoubtedly  a  purely  physical 
sign,  and,  in  the  majority  of  cases,  has  some  definite  anatomic  basis.  The  condi- 
tion commonly  associated  with  true  dysmenorrhea  is  a  local  hypoplasia  of  the 
genital  organs,  in  which  there  usually  exists  a  malposition  of  the  uterus,  in  the 
form  of  a  retrocessed  anteflexion  or  a  retroversion-flexion  of  developmental 
origin,  or  there  may  be  malposition  without  hypoplasia.  In  a  great  number  of 
these  cases  the  individual  is  otherwise  perfectly  normal  and  there  is  often  no 
predisposition  to  lack  of  nervous  equilibrium.  The  painful  periods  at  first  often 
have  little  effect  on  the  patient;  but  gradually,  as  she  grows  from  girlhood  into 
womanhood,  permanent  nervous  manifestations  of  irritability,  exhaustion,  and 
depression  make  their  appearance.  The  curve  of  menstrual  depression  becomes 
deeper  and  deeper,  .and  the  return  to  the  normal  becomes  later  and  later,  during 
the  intermenstrual  period.  Such  patients  no  sooner  recover  from  the  effects 
of  one  period  than  they  begin  to  dread  the  effects  of  the  next  one.  The  condi- 
tion is,  therefore,  one  of  continual  hammering  at  the  patient's  nervous  system 
and  eventuates  gradually  in  seriously  affecting  it.  It  is  no  wonder,  therefore, 
that  patients  with  dysmenorrhea  nearly  always  in  time  become  neurotic.  The 
mistake,  however,  must  not  be  made  in  supposing  that  the  dysmenorrhea  is  in 
these  cases  the  result  of  the  neurotic  condition.  It  is  held  by  some  that  psychic 
and  nervous  conditions  frequently  induce  chronic  dysmenorrhea.  This  may 
possibly  be  true  in  some  instances,  but  it  is  certainly  uncommon.  Such  cases 
are,  therefore,  primarily  for  the  gynecologist,  who  must  do  what  he  can  to 
reueve  the  underlying  pelvic  condition.  Unfortunately,  essential  dysmenor- 
rhea is  difficult  to  treat  successfully,  but  a  certain  percentage  (50  to  75)  yield 
to  surgical  treatment  with  immediate  improvement  of  the  nervous  condi- 
tion.    It  sometimes  happens  that  the  dysmenorrhea  cannot  be  cured  by  any 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  123 

knowTi  means  and  the  patient  develops  into  a  hopeless  invalid,  a  burden  to  her- 
self and  her  friends.  In  these  extreme  cases  castration  with  hysterectomy  is 
justifiable  and  indicated.  In  properly  selected  cases  the  cure  of  the  mental 
and  nervous  condition  may  be  complete. 

Other  irregularities  of  menstruation  besides  dysmenorrhea  may  be  the 
underlying  cause  of  psychoneurotic  conditions.  Menorrhagia,  for  example, 
may  so  deplete  the  patient's  general  health  and  resisting  power  as  to  produce 
neurasthenic  states,  especially  if  there  be  coupled  with  it  the  fear  of  cancer. 
Continued  amenorrhea  may  be;  the  cause  of  mental  depression;  but  where  it  is 
associated  with  grave  mental  disorders,  such,  for  example,  as  dementia  prsecox, 
it  must  be  regarded  only  as  a  sjmiptom  of  the  disease. 

It  should  be  noted  that  disturbed  psychic  states  may  exert  a  certain  amount 
of  temporary  influence  over  the  function  of  menstruation.  It  is  extremely 
common  for  gjmecologic  patients  who  are  being  prepared  for  operation  to 
menstruate  much  out  of  their  regular  time.  Sudden  nervous  or  physical  shocks 
often  bring  on  the  menstrual  flow.  It  is  doubtful  if  ordinary  nervous  shocks 
cause  permanent  irregularity,  though  this  claim  is  frequently  heard.  Fear  or 
nervous  shock  may  also  cause  temporary  amenorrhea,  as  is  often  seen  in  women 
who  fear  impregnation,  the  menstrual  period  sometimes  being  delayed  as  much 
as  ten  days  or  two  weeks  under  the  influence  of  such  apprehension. 

(2)  Influence  of  Menstruation  on  Pathologic  Mental  and  Nervous  Conditions. — ■ 
In  this  class  of  cases  the  primary  seat  of  trouble  is  in  the  nervous  system  itself, 
and  it  includes  everji:hing  from  hereditarj^  functional  disorders  to  serious  organic 
mental  disease.  There  is  no  doubt  that  all  of  these  conditions  may  be  aggra- 
vated during  the  menstrual  period.  If,  in  addition,  the  menses  are  also  ab- 
normal, the  reaction  on  the  nervous  system  is  greatly  increased. 

The  nervous  disturbance  may  be  expressed  only  by  severe  periodic  head- 
aches. Hysteria,  hystero-epilepsy,  epilepsy,  erotomania,  dipsomania,  klepto- 
mania, and  melancholia  frequenth^  appear  chiefly  or  solely  at  the  menstrual 
period.  Women  with  criminal  or  suicidal  tendencies  often  show  their  inchna- 
tions  at  that  time.     To  quote  Havelock  Ellis: 

■'Lombroso  found  that  out  of  80  women  arrested  for  opposition  to  the  poUce,  or  for  assault, 
only  9  were  not  at  the  menstrual  period.  Legi'and  du  SauUe  foxmd  that  out  of  56  women  de- 
tected in  theft  at  shops  in  Paris,  35  were  menstruating.  There  is  no  doubt,  whatever,  that 
suicide  in  women  is  specially  hable  to  take  place  at  this  period;  I&ugelstein  stated  that  in  all 
cases  (107)  of  suicide  in  women  he  had  met  wnth,  the  act  was  conmiitted  during  this  period, 
and,  although  this  cannot  be  accepted  as  a  general  rule  (especially  when  we  bear  in  mind  the 
frequency  of  suicide  in  old  age),  Esquirol,  Brierre,  de  Boismont,  Coste,  Moreau  de  Tours, 
R.  Barnes,  and  many  others  have  noted  the  frequency  of  the  suicidal  tendency  at  this  period. 
In  England  WjTin  Westcott  has  stated  that,  in  his  experience  as  a  coroner,  of  200  women  who 
committed  suicide,  the  majority  were  either  at  the  change  of  Ufe  or  menstruating;  and  in  Ger- 
many HeUer  ascertained  by  postmortem  examination  of  70  women  who  had  committed  suicide 
that  25  (or  in  the  proportion  of  .35  per  cent.)  were  menstruating,  a  considerable  proportion  of 
the  remainder  being  pregnant  or  in  the  puerperal  condition. 


124  GYNECOLOGY 

"Among  the  insane,  finally,  the  fact  is  universally  recognized  that  during  the  monthly 
period  the  insane  impulse  becomes  more  marked,  if,  indeed,  it  may  not  appear  only  at  that 
period.  'The  melancholies  are  more  depressed,'  as  Clouston  puts  it,  'the  maniacal  more  rest- 
less, the  delusional  more  under  the  influence  of  their  delusions  in  their  conduct;  those  subject 
to  hallucinations  have  them  more  intensely,  the  impulsive  cases  are  more  uncontrollable,  the 
cases  of  stupor  more  stupid,  and  the  demented  tend  to  be  excited.'  These  facts  of  morbid 
psychology  are  very  significant;  they  emphasize  the  fact  that  even  in  the  healthiest  woman  a 
worm,  however  harmless  and  unperceived,  gnaws  periodically  at  the  roots  of  life." 

The  preceding  cases  are  primarily  for  the  neurologist  and  the  psychiatrist, 
yet  there  are  certain  of  them  whom  the  gynecologist  may  relieve.  Cases  of 
dysmenorrhea  or  menorrhagia  should  be  submitted  to  the  gynecologist,  for  if 
these  symptoms  can  be  cured  the  patient  is  relieved  of  an  important  nervous 
irritant.  A  limited  number  of  cases  of  this  class  where  the  manifestations 
appear  solely  at  the  catamenial  period  are  subjects  for  castration. 

Genital  Psychoneuroses. — The  term  ''genital  psychoneurosis"  relates  to  a 
condition  of  mind  which  continually  reverts  to  real  or  imaginary  ills  residing 
in  the  pelvic  organs.  In  the  strictest  sense  the  designation  "genital  psychoneu- 
rosis" should  be  applied  only  to  those  cases  in  which  the  genital  organs  are 
actually  sound  and  where  the  subjective  symptoms  are  purely  the  result  of 
imagination.  In  our  experience,  however,  the  pure  genital  neurosis  is  a  com- 
paratively rare  condition,  at  least  in  gynecologic  practice,  the  principal  type 
being  that  of  the  individual  who,  having  some  physical  basis  for  pain  or  discom- 
fort in  the  pelvic  region,  exaggerates  or  overvalues  both  the  pain  and  its  sig- 
nificance. We  may  thus  distinguish  two  types,  one  of  which  we  will  designate 
''the  genital  neurosis  of  imagination"  and  the  other  the  "genital  neurosis  of 
overvaluation."  In  the  former  the  pelvic  organs  are  entirely  normal,  while 
in  the  latter  there  exists  some  pathologic  or  functional  abnormahty.  This 
distinction  is  one  of  much  clinical  importance  for  on  it  depends  the  proper 
treatment  of  the  case. 

Genital  neurotics  of  the  purely  imaginative  type  belong  to  that  class  of  indi- 
viduals who  become  consciously  sensible  of  functions  which  normally  belong  to 
the  realm  of  the  subconscious,  such  as  movements  of  the  intestines,  heart,  and 
stomach,  the  attention  having  been  directed  to  them  accidentally  or  by  the 
pain  of  some  temporary  aberration  of  function.  The  neurosis  consists  in  the 
fixation  or  constant  recurrence  of  the  attention  to  the  new  sensations,  even 
though  the  anatomic  seat  of  the  sensation  is  entirely  normal. 

It  is  a  general  belief  that  neurotics  of  this  kind  are  extremely  common,  a 
belief  that  has  come  down  to  us  from  the  earhest  times,  it  being  supposed  that 
'there  is  some  very  specific  relationship  between  the  female  pelvic  organs  and 
the  nervous  system  Improvement  in  the  study  and  diagnosis  of  both  neurologic 
and  gynecologic  patients  tends  to  show  that  the  number  of  pure  psychoneurotics 
is  much  less  than  was  formerly  supposed,  and  many  cases,  at  one  time  con- 
demned as  hopeless  neurasthenics,  are  now  found  to  be  really  sufferers  from 
physical  conditions  that  often  can  be  alleviated.     This  applies  not  only  to 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  125 

gynecologic  diseases,  but  to  the  affections  of  all  departments  of  medicine  and 
surgery. 

The  manner  in  which  sensations  that  under  normal  conditions  are  sub- 
conscious, or  that  to  the  nervously  sound  are  little  heeded,  come  into  the  realm 
of  consciousness  and  acquire  exaggerated  significance  is  graphically  told  by 
Austen  F.  Riggs,  from  whose  "Talks  to  Patients"  the  following  is  taken. 

Dr.  Riggs  pictures  the  field  of  consciousness  as  a  great  sea  of  immeasurable 
breadth  and  hmitless  depth.  The  surface  of  this  sheet  of  water  is  covered  with 
waves.  Each  impression  made  upon  our  consciousness  from  the  time  of  birth 
to  the  present  moment  is  represented  by  a  wave,  and  the  waves  are  arranged 
in  groups  and  systems  according  to  the  laws  of  association. 

"Now  assume  that  the  whole  sheet  is  in  total  darkness,  save  that  at  or  near  the  middle 
portion  there  is  a  light  suspended  from  above  which  illuminates  a  very  small  area.  It  is  a 
mere  pencil  of  hght,  capable  of  illuminating  but  one  wave  at  a  time,  but  it  has  the  faculty  of  very 
rapid  motion,  and  is  thus  capable  of  illuminating  a  good  many  waves  in  such  quick  succession 
that  it  produces  the  effect  of  having  illuminated  them  almost  simultaneously.  This  light  repre- 
sents the  attention.  To  carry  out  the  figure,  we  must  imagine  ourselves  suspended  above  it 
and  as  being  able  to  control  its  direction  by  our  will.  Just  as  the  searchlight  of  a  battleship  has  a 
definite  range  beyond  which  the  light  does  not  reach,  so  the  light  of  our  attention  can  be  pro- 
jected over  only  a  hmited  area  of  the  sea  of  consciousness.  All  that  lies  outside  this  area,  at 
any  given  moment,  is,  for  that  moment,  subconscious,  so  that  we  speak  of  that  portion  of  con- 
sciousness outside  the  range  of  the  attention  as  the  subconsciousness  and  that  portion  which 
lies  within  the  illuminated  area  as  the  consciousness,  or  more  accurately,  the  former  is  called 
the  unaware  consciousness  and  the  latter  the  aware  consciousness"  ("Talks  to  Patients," 
Elementary  Mental  Mechanics). 


"Most  of  the  time  the  vast  majority  of  these  waves  stay  quietly  in  the  subconscious  region, 
while  only  a  small  minority  pass  in  and  out  of  the  aware  region ;  but  under  certain  circumstances 
a  great  many  may  obtrude  themselves  into  the  illuminated  area,  and  when  this  happens, 
trouble  promptly  ensues. 

"Each  family  of  waves  may  be  said  to  be  made  up  of  two  subgroups;  one  of  which,  com- 
prising the  waves  representing  the  sensations  of  position,  of  vibration,  and  the  deep  muscle  and 
tendon  sensations,  is  a  stable,  stay-at-home  cluster  which  normally  always  remains  in  the  sub- 
consciousness. The  other  subgroup,  which  includes  the  sensations  of  touch,  pain,  and  tempera- 
ture, is  more  mobile,  more  loosely  held  together,  and  thus  many  of  its  members  are  easily  drawn 
from  the  family  circle  into  the  aware  region.  Any  of  these  mobile  sensations  become  very  easily 
accentuated  by  the  ordinary  physical  stimuli  of  the  environment  and  are  thus  constantly 
flashing  in  and  out  of  the  attentive  region.  Even  without  physical  accentuation,  one  or  more 
of  them  may  be  drawn  to  the  attention  if  one  simply  thinks  of  this  or  that  part  of  one's  body, 
and,  consequently,  at  once  becomes  superconscious  of  it. 

"Bearing  this  mechanism  in  mind,  it  is  easy  to  see  that  sensations  of  this  class,  after  being 
repeatedly  picked  out  and  dwelt  upon  by  an  otherwise  idle  attention,  will  form  a  most  unwel- 
come habit  of  finding  their  way  with  greater  and  greater  ease  into  the  aware  consciousness  and 
that  consequently  they  will  become  exaggerated  through  repetition  and  over  attention.  This 
process,  in  fact,  plays  an  important  part  in  the  genesis  of  hypochondriasis,  where  the  sufferer 
becomes  abnormally  aware  of  many,  one  might  almost  say  of  all  of  his  sensations;  and  it  also 
plays  no  smallrole  in  numerous  other  sorts  of  'nervousness.' 

"There  is  another  accident  which  may  occur  in  the  mental  field  which  produces  a  similar 
result.  Not  only  may  the  mobile  sensations  of  the  'touch'  class,  of  which  we  normally  may  or 
may  not  be  aware,  become  accentuated  and  exaggerated,  but  even  those  sensations  of  which 


126  GYNECOLOGY . 

we  are  normally  never  aware,  namely  those  belonging,  to  the  stable,  subconscious  group,  may, 
imder  certain  circumstances,  reach  the  light  of  our  attention.  This  they  do  by  virtue  of  a  proc- 
ess of  disassociation — that  is,  by  a  breaking  up  of  the  normal  arrangement  of  sensations  in  sub- 
groups and  famihes.  Thus  when  a  family  of  sensory  waves  becomes  accentuated  (although 
usually  only  the  more  mobile  subgroup  of  the  touch  and  pain  class  is  aif ected) ,  provided  that 
the  mental  constitution  be  liable  to  disassociation,  the  hghtly  balanced  associative  values  of  a 
whole  family  may  be  upset.  The  result  is  that  one  or  more  sensations  of  the  stay-at-home  group, 
which  should  have  remained  quietly  at  home  in  the  subconsciousness,  now  disassociate  them- 
selves from  this  their  normal  cluster  and  promptly  join  the  other  subgroup  of  the  family. 
They  then  assimie  the  habits  of  their  new  companions  and  wander  with  them  into  the  illumi- 
nated area.  Thus  not  only  does  the  'touch'  sensation  become  prominent,  but  it  drags  with  it 
into  the  aware  field  one  or  more  of  its  normally  subconscious  brothers.  Here,  of  course,  the 
latter  hteraUy  'make  a  sensation.'  They  wear  the  uniform,  let  us  say,  of  the  knee  family  and 
are,  therefore,  recognized  as  hailing  from  the  knee  country;  but  this  is  the  only  famihar  charac- 
teristic they  possess,  and  they  are  above  everything  fascinating  to  the  attention  because  of  the 
utter  strangeness  of  all  their  other  qualities.  They  are  out  of  place — as  startingly  out  of  place 
as  fish  out  of  water.  The  sensations  are  perfectly  normal  in  themselves,  but  they  are  distinctly 
and  markedly  abnormal  in  their  relative  position  in  consciousness.  Like  deep-sea  creatures 
suddenly  hauled  gasping  to  the  surface,  they  are  out  of  their  natural  element,  the  quiet  sub- 
conscious regions,  and  are  showing  themselves  in  the  utterly  strange  environment  of  the 
intensely  active  and  brightly  illuminated  aware  region.  Of  course  they  seem  unnatural,  un- 
desirable, and,  furthermore,  we  treat  them  with  fearful  attention  and  respect,  because  they 
seem  to  signify  that  there  is  something  very  strange  going  on  in  the  bodily  region  from  which 
they  emanate.  The  sufferer  little  realizes  that  their  abnormality  consists  chiefly  in  malposi- 
tion and  not  in  intrinsic  quality  or  significance. 

"Once  having  gained  the  entre,  the  dislocated  sensations  in  question  very  soon  acquire  the 
habit  of  caUing  with  always  greater  frequency  and  famiUarity.  Naturally  the  attention  dwells 
with  greater  and  greater  intensity  upon  its  strange  guests,  and  the  latter  consequently  swell  to 
an  enormous  importance.  Before  long  the  secondary  physical  results  make  their  appearance. 
The  function  over  which  the  sensations  in  question  formerly  presided  without  let  or  hindrance 
now  suffers  overstimulation  or  overinhibition  as  the  case  may  be.  The  sensation,  because  of 
its  abnormal  activity  and  also  because  of  its  malposition  in  consciousness,  has  attracted  more 
than  its  share  of  the  attention,  and  the  latter  consequently  interferes  with  the  nervous  control 
of  the  function"  ("Talks  to  Patients,"  II,  Nervousness). 

Cases  of  pure  psychoneurosis  with  normal  pelvic  organs  belong  to  the 
neurologist  and  psychiatrist.  The  duty  of  the  gynecologist  is  to  isolate  these 
cases  from  those  whose  symptoms  result  from  actual  pelvic  disease.  Obviously, 
patients  whose  symptoms  are  imaginary  are  always  of  a  neurotic  constitution, 
but  patients  whose  nervous  symptoms  are  due  to  the  irritation  of  pelvic  disease 
may  or  may  not  have  had  a  neurotic  predisposition.  Those  whose  nervous 
equilibrium  is  naturally  unstable  succumb  more  readily  to  pelvic  irritants,  but 
even  those  of  the  soundest  constitution  may  become  the  victims  of  serious 
neuroses  if  the  irritation  be  sufficiently  protracted  or  combined  with  other 
elements  of  physical  or  mental  strain. 

In  treating  a  neurotic  patient  who  complains  of  pelvic  pain  or  discomfort 
it  is  the  safest  plan  to  assume  that  the  ills  complained  of  are  actual  and  not  im- 
aginary, though  allowance  may  be  made  for  a  certain  degree  of  exaggeration 
or  overvaluation.  By  not  observing  this  rule  the  gravest  mistakes  are  often 
made. 

The  conditions  which  produce  genital  neuroses  are  more  apt  to  be  the  minor 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  127 

pelvic  affections  which,  without  causing  severe  symptoms,  maintain  a  nagging 
discomfort  and  keep  the  searchhght  of  the  attention  constantly  turned  upon 
them.  The  most  common  and  most  important  source  of  such  neuroses  is  that 
which  comes  from  the  adhesions  of  chronic  pelvic  inflammation.  The  discom- 
fort may  be  caused  by  peritoneal  irritation  or  by  the  immobilization  of  organs 
which  normally  enjoy  free  motion  in  the  pelvis.  Of  these,  the  adnexa  suffer  most, 
and  more  commonly  those  of  the  left  side,  the  pain  usually  being  referred  to  the 
ovary.  The  fact  that  even  extensive  adhesions  may  exist  without  detection  by 
the  most  expert  digital  examination  leads  frequently  to  the  diagnosis  of  psycho- 
neurosis  without  physical  basis,  such  terms  as  "ovarian  neuralgia"  being  used  to 
explain  the  sensations  of  pain. 

Another  most  prohfic  cause  of  neuroses  is  prolapse  of  the  pelvic  organs. 
This  causes  a  sense  of  pressure  and  weight.  The  patient  becomes  actively 
aware  of  her  uterus,  and  finds  it  difficult  to  turn  her  attention  from  it.  The 
exhaustion  that  attends  work  and  physical  effort  deplete  the  strength  and 
stimulate  the  nervous  irritabihty.  Patients  of  the  strongest  nervous  constitu- 
tion are  subject  to  this  form  of  genital  neurosis.  Reconstructive  surgical  opera- 
tions in  this  type  of  case  are  among  the  most  satisfactory  in  gynecologic  practice. 

Tumors  which  are  attended  with  symptoms  of  adhesions  or  pressure,  or  that 
cause  irregular  menstruation  or  mental  anxiety,  produce  neuroses.  Unob- 
served, non-painful  tumors,  on  the  other  hand,  may  reach  large  dimensions 
without  producing  the  least  effect  on  the  nervous  system. 

The  effects  of  irregular  menses  have  already  been  dwelt  upon.  Affections 
of  the  external  genitals  are  often  the  cause  of  severe  nervous  troubles.  Leukor- 
rhea,  functional  incontinence  of  urine,  pruritus  are  of  great  chnical  importance 
in  this  respect,  as  is  pointed  out  in  the  sections  devoted  to  those  subjects.  Senile 
atrophy  and  shrinking  of  the  perineum  deserve  special  mention.  Vaginismus 
is  the  result  either  of  a  pure  neurosis  or  may  be  due  to  some  painful  lesion. 

Many  neuroses  have  a  sexual  origin  and  may  result  from  sexual  disharmony 
between  husband  and  wife,  disappointment  at  not  bearing  children,  fear  of  im- 
pregnation, masturbation,  shame,  etc. 

The  subject  may  be  summed  up  by  the  statement  that  chronic  pelvic  condi- 
tions that  cause  constant  or  frequently  repeated  painful  or  disquieting  sensa- 
tions produce  functional  neuroses  and  psychoneuroses,  the  extent  of  which 
depend  partly  on  the  duration  and  severity  of  the  symptoms  and  partly  on  the 
inborn  lack  of  resistance  to  nervous  stimuli  on  the  part  of  the  patient.  The 
genital  neuroses,  however,  do  not  differ  in  character  from  those  originating  in 
other  parts  of  the  body,  and  do  not  represent  a  mysterious  specific  nerve  con- 
nection between  genitaha  and  brain,  as  was  formerly  supposed.  The  fre- 
quency of  genital  neuroses,  as  compared  with  others,  is  due  to  the  comphcated 
nature  of  the  genital  organs  and  the  ease  with  which  they  are  thrown  out  of  a 
normal  equilibrium. 

The  treatment  of  genital  neuroses  is  directed  toward  the  local  cause  of  irri- 


128  GYNECOLOGY 

tation,  and  requires  exact  diagnosis  and  tactful  judgment,  for  if  cases  of  this 
kind  are  improperly  treated  the  effects  are  serious.  The  success  in  treatment 
depends  on  relieving  the  irritating  local  symptoms.  If  pelvic  disease  can  be 
definitely  excluded  the  patient  should  be  treated  neurologically,  for  in  this 
case  all  forms  of  gynecologic  treatment  are  usually  harmful. 

Effects  of  Castration. — The  subject  of  postoperative  neuroses  following 
hysterectomy  and  castration  is  of  special  interest  to  the  gynecologist  because  of 
the  frequency  with  which  this  operation  must  be  performed,  and  because  of  the 
popular  belief  that  ablation  of  the  uterus  and  ovaries  is  followed  by  serious 
nervous  disturbances  that  may  even  amount  to  insanity.  That  this  notion  is 
very  greatly  exaggerated  is  proved  by  the  experience  of  present-day  surgeons. 
It  has  been  our  observation  that  the  artificial  menopause  causes  no  more  dis- 
turbance than  does  a  normal  change  of  life. 

The  nervous  symptoms  of  the  menopause  may  be  divided  into  two  distinct 
groups,  the  vasomotor  and  the  psychoneurotic.  Vasomotor  symptoms  are 
represented  chiefly  by  hot  flushes,  though  there  may  be  other  manifestations 
of  dizziness,  cold  extremities,  etc.  In  our  series  of  cases  vasomotor  disturbances 
appeared  in  80  per  cent,  after  castration.  The  average  duration  of  these  symp- 
toms is  from  two  to  three  months,  though  they  may  last  longer.  Painful  or 
irritating  complications  after  operation,  such  as  hernia,  postoperative  adhesions, 
wound  infections,  and,  especially  prolapse  of  the  cervical  stump  and  vaginal 
wall,  tend  to  make  the  symptoms  more  severe  and  to  prolong  them  over  a  greater 
period  of  time.  Ovarian  extract  acts  as  a  specific  for  the  vasomotor  changes, 
almost  invariably  relieving  them. 

The  cause  of  hot  flushes  is  in  some  way  related  to  the  removal  of  the  ovaries, 
but  in  just  what  way  the  change  takes  place  is  not  definitely  known.  Schickele 
ascribes  them  to  a  heightened  blood-pressure,  due  to  the  removal  of  the  vaso- 
depressor influence  of  the  ovarian  internal  secretion.  Observations  made  at 
the  Free  Hospital  for  Women  in  a  series  of  about  50  cases  have  failed  to  reveal 
a  single  instance  of  increased  blood-pressure  following  castration. 

That  hot  flushes  are  influenced  by  some  other  factor  or  factors  is  shown 
by  their  frequent  appearance  in  women  who  possess  functionating  ovaries. 
In  one  of  our  cases,  a  patient  with  uterine  insufficiency  who  had  suffered  severely 
from  hot  flushes  for  several  years,  the  symptoms  completely  disappeared  after 
hysterectomy  and  castration. 

Vasomotor  disturbances  do  not  usually  produce  nervous  symptoms  unless 
they  are  very  severe  or  frequent,  in  which  case  they  sometimes  react  seriously 
on  the  nervous  system  in  the  same  way  as  any  other  physical  irritant. 

Psychoneuroses,  as  distinguished  from  vasomotor  disturbances,  are  by  no 
means  definitely  consequent  on  the  loss  of  the  ovaries.  On  the  contrary, 
psychoneurotic  conditions  are  again  and  again  relieved  or  completely  cured 
by  a  hysterectomy  operation  which  has  relieved  the  patient  of  some  painful 
irritant  hke  that,  for  example,  of  a  pelvic  infiammation. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      129 

Severe  psychoneuroses  may  follow  hysterectomy,  but  they  are  brought 
about  in  the  following  ways:  The  operation  may  have  been  misdirected  and 
not  indicated  in  the  first  place,  or  it  may  have  been  improperly  performed,  or 
surgical  complications  may  have  ensued  which  have  left  the  patient  in  a  painful, 
uncomfortable  state.  As  proof  of  this  is  the  fact  that  postoperative  neuroses 
following  hysterectomy  were  formerly  far  more  common  not  many  years  ago 
than  they  are  now.  This  can  only  be  explained  on  the  ground  that  the  technic 
of  the  operation  has  in  the  last  few  years  been  very  greatly  improved,  so  that 
now  if  it  is  properly  done  there  is  no  shock,  no  postoperative  prolapse  of  the 
vagina,  no  pelvic  adhesions  and  'other  unfortunate  complications,  which,  if 
present,  cause  nagging  discomforts  that  are  sure  to  disarrange  the  nervous 
mechanism. 

Another  important  cause  of  the  psychoneuroses  of  the  artificial  meno- 
pause is  that  resulting  from  mental  suggestion.  Under  normal  conditions  a 
woman  does  not  instinctively  suffer  a  sense  of  physical  degradation  from  the 
loss  of  her  pelvic  organs,  especially  if  such  a  loss  is  attended  with  a  relief  of  pain. 
This  sense  of  degradation  may,  however,  be  very  powerfully  induced  by  the  criti- 
cism of  an  unfeeling  husband  or  the  suggestions  of  unwise  friends,  by  which 
the  patient  is  led  to  contemplate  her  inabiUty  to  bear  children  or  to  fear  the 
loss  of  youth  and  the  premature  onset  of  old  age.  Under  such  conditions  the 
mental  distress  may  result  in  severe  psychoneuroses.  Such  a  state,  however, 
must  be  regarded  as  due  to  psychic  irritation,  and  not,  in  any  sense,  as  a  specific 
consequence  of  the  loss  of  ovarian  secretion. 

What  has  been  said  concerning  the  nervous  disturbances  of  the  artificial 
menopause  is  also  true  of  the  physiologic  menopause,  in  which  vasomotor 
and  psychoneurotic  symptoms  may  appear.  Dubois,  after  studying  many 
cases  for  a  period  of  more  than  thirty  years,  has  come  to  the  conclusion  that 
the  neurotic  manifestations  are  largely  due  to  mental  suggestion  as  a  result  of 
the  cares  and  worries  and  apprehensions  that  are  usually  incident  at  the  period 
of  the  climacteric. 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE  SEX  IMPULSE 

A  study  of  the  sexual  impulse  in  woman  includes  a  consideration  of  every 
period  of  life  from  earliest  infancy  to  extreme  old  age.  Until  comparatively 
recent  times  normal  sexual  activity  was  supposed  to  begin  only  at  the  time  of 
puberty  and  the  appearance  of  menstruation.  Before  that  period  manifestations 
of  a  sexual  character  were  for  the  most  part  regarded  as  abnormal  and  as  evidence 
of  disease  or  of  some  hereditary  degenerative  taint. 

Kisch,  in  his  monumental  work  on  the  sexual  life  of  woman,  begins  at  what 
he  terms  the  menarche  (puberty),  entirely  disregarding  childhood.  Lowenfeld 
remarks  "that  the  manifestations  of  the  sexual  impulse  are  not  normally  present 
in  the  days  of  childhood,"  and  that  when  the  impulse  does  appear  it  is  either  the 

9 


130  GYNECOLOGY 

result  of  pathologic  conditions  that  affect  the  genital  organs  or  of  chance  impres- 
sions or  bad  example.  To  Freud  must  be  given  the  full  credit  of  first  recognizing 
the  normality  of  the  sex  impulse  in  childhood  and  of  calling  attention  to  the 
enormous  influence  which  infantile  and  adolescent  sexuality  has  on  the  mental 
and  physical  character  of  the  adult.  The  theories  of  Freud  have  not  been 
received  without  intense  opposition,  but  they  have  finally  come  to  be  so  widely 
accepted,  both  by  the  medical  profession  and  by  psychologists,  that  they  cannot 
be  disregarded  in  a  work  of  this  kind. 

Freud  attributes  the  little  value  that  has  in  the  past  been  ascribed  to  the 
childhood  period  of  sexual  development  to  the  universal  infantile  amnesia 
which  "causes  the  individual  to  look  upon  his  childhood  as  if  it  were  a  prehistoric 
time  and  conceals  from  him  the  beginning  of  his  own  sexual  life."  Freud,  how- 
ever, has  been  able  to  show  that  during  the  forgotten  period  of  childhood  the 
most  important  and  lasting  impressions  are  made  on  the  childish  mind,  which, 
though  lying  latent  and  forgotten  in  the  subconscious,  actually  continue  to  exert 
a  powerful  influence  on  the  qualities  and  reactions  of  the  individual  throughout 
his  lifetime. 

In  considering  Freud's  views  on  infantile  sexuality  it  must  be  remembered 
that  we  are  studying  the  impulse  in  its  various  stages  of  development;  that  is  to 
say,  the  sex  manifestations  of  the  young  child  are  essentially  rudimentary  and  are 
in  no  way  equivalent  to  the  physico-psychic  sex  reactions  of  the  matured  indi- 
vidual. Failure  to  appreciate  this  fact  has  led  many  to  regard  the  Freudian 
theories  with  abhorrence.  As  Trotter  puts  it,  it  is  like  the  embryology  of  the 
body,  which  to  persons  with  no  biologic  training  is  far  from  being  a  gratifying 
subject  of  contemplation. 

INFANTILE   SEXUALITY 

According  to  Freud  the  newborn  child  brings  with  it  rudimentary  sexual 
impulses  which  normally  make  their  appearance  at  certain  stages  of  the  child's 
life  with  intervening  periods  of  latency.  These  early  rudimentary  impulses  are 
very  complex  and,  as  will  be  explained  later,  include  perverse  as  well  as  so-called 
natural  instincts.  The  first  instinct  that  the  child  exhibits  is  that  for  nourish- 
ment, which  is  obtained  by  sucking  its  mother's  breast.  The  act  of  sucking,  first 
employed  for  appeasing  hunger,  is  soon  found  to  be  soothing  and  pleasurable,  and 
the  child  resorts  to  it  often  when  not  hungry,  thereby  inducing  sleep.  The  act 
of  nursing,  notwithstanding  its  primary  object,  is  to  be  regarded  as  the  earliest 
manifestation  of  the  sexual  impulse,  a  fact  not  to  be  wondered  at  in  view  of  the 
close  association  of  the  hunger  and  sex  instincts  that  later  in  life  are  sufficiently 
obvious.  The  pleasurable  sensation  excited  by  the  act  of  nursing  leads  the  infant 
to  seek  other  objects  for  sucking  more  accessible  than  the  mother's  nipple. 
This  practice,  which  to  a  certain  extent  is  universal  among  babies  and  is,  within 
limits,  physiologic,  disappears  in  time  and  is  harmless.  It  may,  however,  become 
excessive  and  be  the  starting-point  of  serious  later  developments.     The  objects 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  131 

most  frequently  chosen  for  sucking  are  parts  of  the  infant's  own  body,  especially 
the  thumb,  the  tongue,  a  part  of  the  lip  itself,  or  the  great  toe.  Associated  with 
the  act  of  sucking  there  is  often  a  rhythmic  pulling  of  the  lobe  of  the  ear,  or  the 
rubbing  of  certain  sensitive  parts  of  the  body.  This  habit  completely  occupies 
the  attention  of  the  child  and  leads  to  sleep  and  sometimes  to  a  reaction  resem- 
bling an  orgasm.  That  thumb-sucking  is  a  sexual  manifestation  is  often  recog- 
nized by  parents  who  are  vaguely  aware  that  the  child  is  doing  something  wrong 
and  who  strive  to  break  the  habit.  Such  a  habit  often  persists  for  years,  some- 
times for  a  lifetime,  and  probably  in  the  majority  of  cases  leads  directly  to 
masturbation.  Freud  finds  among  men  a  definite  relationship  between  energetic  ^ 
infantile  thumb-sucking  and  a  later  tendency  to  excessive  drinking  and  smoking, 
while  among  women  he  shows  that  it  may  lead  in  adult  life  to  certain  Hp  perver- 
sions, or,  if  repressed,  to  hysteric  symptoms  connected  with  eating,  such  as 
globus  hystericus,  choking  sensations,  and  vomiting.  Thumb-sucking,  which  is 
only  one  of  several  examples  of  infantile  sexual  activity,  illustrates  the  theory  of 
erogenous  zones,  a  term  adopted  by  Freud  from  von  Kraft-Ebing  and  defined  by 
the  latter  as  ' 'portions  of  the  skin  or  mucous  membrane  in  which  stimuli  produce  a 
feeling  of  pleasure  of  definite  quahty."  Examples  of  these  sensitive  areas  are 
the  lips  and  mucous  membrane  of  the  mouth,  the  nipples,  the  anus,  the  neck  o: 
the  bladder,  the  buttocks,  and  the  external  genitals.  As  will  be  seen  later,  undue 
early  excitation  of  any  one  of  these  zones  may  produce  an  abnormal  sensibility 
of  that  particular  part  of  the  body  and  evoke  in  after  years  certain  sexual  aber- 
rations from  habitual  gratification,  or  neuroses  from  repression  of  the  unnatural 
impulse.  In  habitual  thumb-sucking  we  have  an  illustration  of  abnormal  stimula- 
tion of  the  lip-and-mouth  erogenous  zone. 

The  sexual  impulse  of  the  child  is  essentially  auto  erotic,  that  is  to  say,  the 
sexual  aim  is  directed  to  some  portion  of  the  child's  own  body,  usually  one  of 
the  erogenous  zones.  At  birth  the  various  zones  are-each  susceptible  of  develop- 
ing into  predominant  sexual  areas  if  subjected  to  special  excitation,  a  point 
which  will  be  seen  to  be  of  importace  in  determining  some  of  the  perversions. 
Nature,  however,  provides  that  under  normal  conditions  certain  zones  only  shall 
be  stimulated  for  future  sexual  activity.  Thus  the  act  of  nursing  prepares  the 
lip  zone,  so  that  it  plays  a  prominent  part  sexually  during  life.  Freud  sees  in  the 
irritation  from  uncleanliness,  cleansing,  chafing,  etc.,  nature's  provision  for  the 
early  excitation  of  the  genital  zone.  The  infant  soon  recognizes  the  pleasurable 
sensibility  of  this  area  and  learns  to  repeat  the  experience  by  onanism,  even 
during  the  nursing  age.  In  girls  this  is  accomplished  either  with  the  hand  or  by 
pressure  of  the  thighs.  So  nearly  universal  is  this  phenomenon  that  Freud 
regards  it  as  a  physiologic  reaction  which  serves  to  estabHsh  the  future  primacy 
of  the  genital  zone.  The  first  phase  of  infantile  onanism  is  usually  of  brief  dura- 
tion, though  it  may  continue  indefinitely  and  provide  a  permanent  deviation 
from  normal  sexual  development. 

At  about  the  fourth  year  in  most  children  there  is  a  second  reawakening 


132  GYNECOLOGY 

of  the  sexual  impulse,  and  again  there  is  a  period  of  onanistic  activity  which  is 
also  normally  of  short  duration.  Both  the  incidence  and  duration  of  this  period 
varies  considerably  in  different  individuals.  Girls  do  not  escape  this  experience 
and  there  is  some  ground  for  belief  that  both  this  and  the  infantile  period  of 
masturbation  are  more  common  in  them  than  in  boys.  In  the  second  period 
the  sexual  demand  in  girls  is  apparently  not  necessarily  determined  by  local 
irritation,  but  may  be  of  central  origin.  It  is  characterized  by  a  sudden  itching 
or  prurient  sensation,  often  of  a  disagreeable  nature,  which  is  commonly  reUeved 
by  the  hand  or  by  pressure  of  the  body  against  some  projecting  object  or  by 
bodily  movements  with  the  thighs  closed.  The  sensation  and  its  reHef  may  be 
induced  by  such  exercises  as  riding  a  bicycle,  swinging,  rocking,  riding  in  rail- 
road trains,  etc.  In  its  physiologic  phase  the  onanism  of  childhood  is  not  asso- 
ciated with  psychic  sexual  phantasies. 

Freud  rightly  emphasizes  the  great  importance  of  the  influence  of  the  second 
stage  of  childhood  masturbation  on  the  future  character  of  the  individual.  At 
this  period  there  begins  to  develop  in  the  child's  mind  forces  which  inhibit  the 
sexual  impulse  and  which  find  their  expression  in  a  sense  of  shame  and  loathing. 
This  sexual  barrier,  as  it  is  termed,  is  not  essentially  the  outcome  of  parental 
,'liscipline  and  education,  but,  as  Trotter  has  pointed  out,  is  a  true  instinct.  In 
a  normally  or,  one  might  say,  ideally  developing  and  properly  protected  child 
the  psychic  barrier  completely  overcomes  the  masturbatic  tendency  and  there 
ensues  a  latent  period  until  the  next  stage  of  sexual  awakening.  During  the 
latent  period  not  only  does  the  psychic  inhibition  prevent  sexual  practices  on 
the  part  of  the  child,  but  it  inspires  loathing  at  the  appearance  of  such  inclina- 
tions in  other  children  or  in  older  persons.  The  normal  child  is,  therefore,  to  a 
certain  extent  automatically  protected  from  the  dangers  of  seduction  and  enters 
on  the  age  of  puberty  well  prepared  for  the  serious  problems  of  life. 

For  .many  children,  however,  the  latent  period  is  a  critical  age.  If  the  psychic 
barrier  is  weak  either  from  hereditary  predisposition  or  from  unfavorable  en- 
vhonment,  or  from  both  causes  working  together,  the  sexual  activity  of  mid- 
cliildhood  may  continue  and  become  intensified.  Under  such  conditions  the 
child  is  an  easy  prey  to  the  influences  of  seduction  or  evil  impressions  and  the 
sexual  stream  may  flow  readily  into  some  perverted  channel.  In  other  cases 
the  psychic  barrier,  though  it  may  succeed  in  repressing  the  sexual  impulse, 
appears  too  late  and  brings  about  a  conflict  so  severe  that  it  leaves  in  the  childish 
mind  a  profound  traumatic  impression  which  may  reappear  in  later  years  in 
the  form  of  some  serious  neurosis.  It  is  in  cases  of  this  kind  that  Freud  has  car- 
ried out  his  deepest  researches  and  made  his  most  important  discoveries. 

Up  to  the  time  of  puberty  the  sexes  do  not  differ  greatly  in  regard  to  their 
sexual  activity,  though  it  may  be  said  that  the  inhibitive  instinct  seems  to  appear 
earUer  and  more  effectively  in  girls  than  in  boys.  At  iSie  beginning  of  puberty, 
however,  a  marked  divergence  between  the  two  sexes  takes  place.  In  the  boy 
very  definite  and  consistent  sexual  changes  take  place  concomitant  with  the 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  133 

rapid  development  of  the  genital  apparatus.  These  may  be  summed  up  in  the 
appearance  of  the  libido,  powerful  attraction  toward  the  opposite  sex,  and  a  more 
or  less  periodic  discharge  of  the  sexual  products.  In  normal  boys  the  sexual 
experience  is  constant,  showing  comparatively  little  variation  in  different  indi- 
viduals. In  girls,  on  the  other  hand,  the  sexuahty  of  puberty  is  not  as  well  de- 
fined. In  them  the  libido  is  not  regularly  awakened  as  a  result  of  the  physiologic 
and  anatomic  changes  of  puberty,  but  depends  for  its  excitation  on  an  external 
stimulus,  such  as  seduction,  love,  onanism,  suggestion  from  books,  etc.  Hence  in 
guis  puberty  and  the  awakening  of  the  hbido  are  not  necessarily  contemporaneous. 
The  way  in  which  full  sexual  sensibihty  is  developed  may  be  best  understood 
by  the  following  quotation  from  Freud  : 

"In  respect  to  the  auto-erotic  and  masturbatic  sexual  manifestations  it  may  be  asserted 
that  the  sexuahty  of  the  httle  girl  has  entirely  a  male  character.  Indeed,  if  one  could  give  a 
more  definite  content  to  the  terms  'masculine'  and  'feminine,'  one  might  advance  the  opinion 
that  the  libido  is  regularly  and  lawfully  of  a  masculine  nature,  whether  in  the  man  or  in  the  woman ; 
and  if  we  consider  its  object,  this  may  he  either  the  man  or  the  woman. 

"The  chief  erogenous  zone  in  the  female  child  is  the  clitoris,  which  is  homologous  to  the 
male  penis.  All  I  have  been  able  to  discover  concerning  masturbation  in  httle  girls  concerned 
the  clitoris  and  not  those  other  external  genitals  which  are  so  important  for  the  later  sexual 
functions.  With  few  exceptions  I  myself  doubt  whether  the  female  child  can  be  seduced 
to  anything  but  chtoris  masturbation.  The  frequent  spontaneous  discharges  of  sexual  ex- 
citement in  Mttle  girls  manifest  themselves  in  a  twitching  of  the  chtoris,  and  its  frequent 
erections  enable  the  girl  to  understand  correctly  even  without  any  instruction  the  sexual 
manifestations  of  the  other  sex;  they  simply  transfer  to  the  boys  the  sensations  of  their  own 
sexual  processes. 

"If  one  wishes  to  understand  how  the  little  girl  becomes  a  woman  he  must  follow  up  the 
further  destinies  of  this  chtoris  excitation.  Puberty,  which  brings  to  the  boy  a  great  advance 
of  libido,  distinguishes  itself  in  the  girl  by  a  new  wave  of  repression  which  especially  concerns 
the  chtoris  sexuality.  It  is  a  part  of  the  male  sexual  life  that  sinks  into  repression.  The  re- 
inforcement of  the  sexual  inhibitions  produced  in  the  woman  by  the  repression  of  puberty 
causes  a  stimulus  in  the  libido  of  the  man  and  forces  it  to  increase  its  capacity;  with  the  height 
of  the  libido  there  is  a  rise  in  the  overestiniation  of  the  sexual,  which  can  be  present  in  its  fuU 
force  only  when  the  woman  refuses  ajid  denies  her  sexuality.  If  the  sexual  act  is  finally  sub- 
mitted to  and  the  clitoris  becomes  excited  its  r61e  is  then  to  conduct  the  excitement  to  the 
adjacent  female  parts,  and  in  this  it  acts  hke  a  chip  of  pine  v/ood  which  is  utilized  to  set  fire  to 
the  harder  wood.  It  often  takes  sorne  time  for  this  transference  to  be  accomplished,  during 
which  the  young  wife  remains  anesthetic.'^ 

The  sexual  life  of  the  first  part  of  normal  womanhood  may  be  thus  reca- 
pitulated :  The  first  sexual  activity  appears  in  earliest  infancy  and  results  from 
the  pleasurable  sensations  of  nursing.  It  is  manifested  often  by  thumb-sucking, 
masturbation,  and  other  equally  significant  acts  associated  with  certain  areas 
of  the  body  termed  erogenous  zones. 

A  second  period  of  sexuality  appears  at  about  the  age  of  four  to  six  and  is 
characterized  chiefly  by  masturbation  of  the  chtoris.  This  period  is  under  normal 
conditions,  of  comparatively  short  duration  and  is  terminated  bj^  the  develop- 
ment of  the  psychic  barrier,  which,  supplemented  by  parental  discipHne,  causes 
the  child  to  repress  the  masturbatic  practice.  After  the  termination  of  the  onan- 
istic  period  of  childhood  the  little  girl's  life  is  apparently  asexual.    At  puberty 


134  GYNECOLOGY 

there  takes  place  a  fresh  wave  of  repression  in  contrast  to  the  flood  of  libido 
which  occurs  in  boys.  The  repressive  inhibition  lasts  through  maidenhood  and 
may  be  regarded  as  a  provision  of  nature  in  that  it  furnishes  the  resistance  neces- 
sary for  the  highest  effectiveness  of  the  male  libido.  At  the  first  coitus  the 
normal  woman  is  often  anesthetic  and  may  remain  so  until  the  clitoris  is  able 
to  conduct  its  excitability  to  the  adjacent  parts  and  especially  to  the  vagina. 
This  period  of  sexual  anesthesia  may  continue  for  several  weeks  or  months. 
Occasionally  it  lasts  until  after  the  birth  of  the  first  child.  This  temporary 
anesthesia  of  the  newly  married  woman  is  not  to  be  regarded  as  pathologic, 
although  it  sometimes  is  the  exciting  cause  of  an  anxiety  neurosis.  When  full 
sexual  sensibility  has  been  e^r'iabKshed  the  libido  of  woman  becomes  mascuHne 
in  type,  though  between  man  and  woman  the  component  parts  of  the  libido  may 
exhibit  variations  in  intensity.  Thus  in  woman  the  psychic  element  is  often 
more  powerful  than  the  somatic,  as  compared  with  man,  though  in  some  in- 
stances the  conditions  may  be  reversed. 

The  asexual  period  of  maidenhood  described  above  may  be  regarded  as  the 
ideally  normal,  and  is  undoubtedly  the  best  preparation  for  the  later  duties 
of  wife  and  motherhood,  in  that  it  makes  for  greater  mental  and  social  stability. 
The  adolescent  period  is,  however,  pecuHarly  liable  to  sexual  interruptions 
such  as  may  result  from  multiple  ^love  affairs,  lax  social  environment,  onanism, 
evil  suggestion,  etc.  Women  who  during  their  maidenhood  period  experience 
such  interruptions  are  especially  subject  to  neuroses  and  are  prone  later  to  be- 
come irritable  and  discontented  in  married  life. 

During  the  first  part  of  married  life  the  participation  of  woman  in  the  con- 
jugal relation  is  more  that  of  passive  acquiescence.  After  the  birth  of  children 
and  as  physical  attraction  wanes  it  frequently  happens  that  the  role  of  sexual 
initiative  between  the  partners  is  reversed.  The  sexual  libido  of  woman  does 
not  cease  at  the  menopause,  but  may  continue  indefinitely  afterward.  During 
the  period  of  the  climacteric  there  is  often  an  increase  in  intensity  which  under 
pathologic  conditions  may  amount  to  n3miphomania.  After  the  menopause 
the  libido  gradually  diminishes,  more,  in  all  probability,  from  disuse  and  repres 
sion  than  from  a  physiologic  disappearance  of  the  emotion. 

Libido  and  sexual  sensibility  are  not,  as  a  rule,  destroyed  by  castration  in 

adult  life. 

SEXUAL  DEVIATIONS 

Masturbation. — Of  the  various  sexual  deviations  to  which  woman  is  subject 
the  most  important  is  masturbation,  a  fact  that  is  not  fully  appreciated.  Not 
only  is  its  frequency  underestimated,  but  its  influence  on  character  and  health 
has  received  too  little  attention. 

The  subject  of  masturbation  is  not  as  well  understood  in  woman  as  it  is  in 
man.  Much  of  the  evidence  in  the  literature  is  vague  and  contradictory.. ,  It 
therefore  becomes  necessary  to  weigh  judicially  the  evidence  that  is  available 
and  with  the  aid  of  clinical  observations  to  draw  such  conclusions  as  seem  most 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  135 

reasonable.  Freud's  theories  on  infant  sexuality,  cited  above,  throw  a  new  light 
on  the  masturbation  of  childhood.  If  these  theories  be  accepted,  we  must  re- 
gard as  physiologic  the  brief  onanistic  periods  of  the  nursing  stage  and  of  mid- 
childhood.  These  two  manifestations  of  sex  activity  are  practically  alike  in  the 
two  sexes  and  in  no  sense  indicate  degenerative  hereditary  tendencies.  On  the 
contrary,  they  are  a  provision  of  nature  to  prepare  the  genital  zone  for  its  ulti- 
mate sexual  primacy,  and  their  failure  to  appear  may  even  denote  an  inborn 
sexual  deficiency.  If,  however,  they  are  not  duly  checked  by  the  inhibitions 
which  nature  also  -provides,  then  masturbation  becomes  pathologic.  The  per- 
sistence of  the  practice  beyond  its  physiologic  limits  may  indicate  an  hereditary 
predisposition  or  it  may  be  the  result  of  an  unfavorable  environment.  There  is 
no  doubt  that  during  the  latent  period  of  childhood  an  occasional  infrequent 
recurrence  of  the  prurient  sensation  of  the  clitoris  demanding  gratification 
may  take  place  in  entirely  normal  individuals,  especially  in  those  who  in  mature 
life  develop  strong  sexual  impulses.  When,  however,  the  recurrence  is  so  fre- 
quent as  to  form  an  established  habit,  it  must  be  regarded  with  concern.  Al- 
though it  is  frequently  asserted,  and  probably  with  truth,  that  onanism  in  the 
adult  woman  is  less  harmful  than  it  is  in  man,  the  same  assertion  cannot  be 
made  of  onanism  of  the  latent  period  of  childhood,  for  girls  are  peculiarly  sus- 
ceptible to  the  abnormal  psychic  reactions  to  which  the  practice  leads. 

When  onanism  becomes  excessive  in  a  child  the  condition  is  a  difficult  one 
to  combat.  In  extreme  cases  the  craving  is  incessant  and  insatiable.  Preven- 
tion by  tying  the  hands  or  by  other  mechanical  means  is,  for  the  most  part,  futile, 
for  orgasm  can  be  accomplished  by  simple  movements  of  the  body.  Excepting 
in  cases  where  onanism  is  a  syndrome  of  mental  degeneracy  the  onanistic  child 
is  frequently  prematurely  bright  and  intelligent.  When  t*e  psychic  barrier  is 
entirely  inactive  the  child  exhibits  no  sense  of  shame  and  is  frank,  cheerful,  and 
care  free.  In  this  type  of  case  there  are  often  no  signs  of  physical  detriment. 
Such  cases,  however,  must  be  kept  from  contact  with  other  children,  for  in  addi- 
tion to  the  auto-erotic  impulse  which  leads  them  to  constant  masturbation  there 
exists  almost  invariably  a  tendency  to  communicate  their  experiences  to  com- 
panions either  male  or  female.  They  become,  therefore,  a  dangerous  source  of 
seduction. 

The  future  of  the  childish  victim  of  uninhibited  onanism  is  not  easy  to  prog- 
nosticate. Where  hereditary  degenerative  influences  play  a  part  the  masturba- 
tive  tendency  may  be  a  prodrome  to  some  later  serious  psychosis.  In  other  cases 
the  onanistic  impulse  which  during  childhood  is  auto-erotic  may  become  frankly 
altruistic,  that  is,  directed  to  others  of  the  same  sex.  In  this  way  the  child  may 
develop  sooner  or  later  into  an  invert  or  homosexualist.  Such  individuals  may 
be  entirely  normal  in  every  other  way  and  often  show  great  intellectual  power 
and  productiveness  in  mature  life. 

In  still  other  cases  the  normal  repressive  reaction  of  female  puberty  may 
check  the  onanistic  tendency,  and  under  proper  environmental  influences  the 


136  GYNECOLOGY 

sexual  stream  may  eventually  be  directed  into  normal  channels,  though  neurotic 
stigmata  are  comparatively  certain  to  appear. 

So  far  we  have  discussed  what  we  have  chosen  to  term  the  "uninhibited 
masturbator,"  that  is  to  say,  the  child  in  whom  the  psychic  barrier  of  shame 
and  self-reproach  has  failed  to  act. 

There  is  another  important  type,  where  the  psychic  barrier,  though  strong, 
only  incompletely  overcomes  the  sexual  impulse.  The  result  is  a  continual  men- 
tal conflict  which,  as  Freud  has  shown,  may  lay  the  foundation  of  a  later  neurosis. 
Individuals  of  this  type  often  suffer  more  physical  detriment  than  do  those  of 
the  uninhibited  class.  They  are  frequently  meager  and  sallow  in  appearance, 
subject  to  digestive  disturbances,  non-resistant  to  disease,  mentally  sluggish 
and  apathetic,  secretive,  and  antisocial.  Between  the  two  extremes  of  type  there 
are  all  gradations.  From  the  time  of  puberty  to  the  time  of  female  maturity, 
usually  estimated  at  nineteen,  masturbation  is  not  physiologic,  as  to  a  certain 
extent  it  may  be  regarded  in  boys.  If  habitual  masturbation  occurs  in  the 
adolescent  girl  it  is  either  a  continuation  of  abnormal  childhood  onanism,  or 
if  it  appears  for  the  first  time,  it  is  the  result  of  a  prematurely  stimulated  but 
ungratified  sexual  activity.  What  has  been  said  of  masturbation  of  the  latent 
period  of  childhood  may  be  applied  for  the  most  part  to  the  period  of  adolescence 
with  some  modifications.  When  the  habit  is  excessive  it  is  usually  associated 
with  some  mental  disorder.  Patients  of  this  kind  often  suffer  from  severe  and 
extensive  vulvitis  as  a  result  of  manipulative  irritation  (see  Vulvitis).  Newly 
acquired  masturbation  at  this  age  usually  does  not  lead  to  serious  results. 

Early  masturbation  is  a  poor  preparation  for  married  life,  for  those  addicted 
to  the  habit  are  apt  to  be  anesthetic  in  normal  coitus.  This  is  explained  by  the 
fact  that  continued  excitation  of  the  clitoris  causes  a  fixation  of  sexual  sensibility 
to  that  particular  zone.  When,  therefore,  normal  coitus  takes  place  the  clitoris 
permanently  refuses  to  give  up  its  excitability  to  the  zones  of  the  vulva  and 
vagina,  which  play  an  absolutely  essential  part  in  complete  natural  orgasm. 
Thus  masturbation  continued  from  childhood  is  rightly  classed  as  an  infantile 
fixation,  and  is  comparable  from  a  neurologic  standpoint,  though  not  necessarily 
concomitant,  with  those  anatomic  fixations  which  are  so  common  in  the  female 
pelvic  organs. 

Early  continued  onanism  has  an  important  influence  on  the  character  of 
woman,  for  in  addition  to  the  neuroses  which  it  induces  it  is  extremely  apt  to 
be  instrumental  in  fixing  certain  traits  of  disposition  that  belong  essentially  to 
childhood.  The  infant  is  not  only  sexually  auto-erotic,  but  is  also  otherwise 
psychically  egocentric.  We  have  seen  that  the  auto-erotic  tendency  of  mid- 
childhood  is  soon  checked  by  the  development  of  the  psychic  barrier  which 
creates  feelings  of  shame  and  self-reproach.  This  psychic  barrier  is,  in  reality, 
the  herd  instinct  which  by  antagonizing  selfish  impulses  adapts  the  individual 
to  social  surroundings.  If  the  psychic  barrier  is  incapable  of  checking  the  auto- 
erotic  tendency  as  is  manifested  by  continued  masturbation  it  may  fail  also  to 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  137 

check  other  egocentric  impulses  not  essentially  sexual,  such  as  jealousy,  cruelty, 
dependence,  and  self-will,  which  are  characteristic  of  the  infant's  nature.  Thus, 
traits  of  this  kind  may  become  fixed,  and  individuals  who  exhibit  them  in  mature 
life  are  said  to  be  subjects  of  'psychic,  infantilism.  Psychic  infantilisms  of  char- 
acter are  not  necessarily  conditioned  on  early  masturbation,  though  it  is  probable 
that  when  they  are  well  marked  they  are  usually  the  stigma  of  some  early  sexual 
irregularity. 

The  prevalence  of  masturbation  in  matured  women  is  problematic,  but  it  is 
undoubtedly  far  more  common  than  is  generally  supposed.  Gutceit  is  of  the 
opinion  that  after  the  age  of  nineteen  or  twenty  "sexual  self -gratification  is 
almost  universally  practised  by  women,  even  if  it  be  not  always  practised  to 
excess,"  but  the  statement  probably  is  an  exaggeration.  It  is  impossible  to 
secure  exact  data  concerning  the  onanism  of  maturity,  as  women  are  habitually 
secretive  and  deceptive  on  this  subject.  From  what  evidence  we  have  we  are 
led  to  believe  that  women  who  have  indulged  in  the  habit  in  earlier  life  beyond 
the  physiologic  limit,  either  continue  or  resume  it  to  a  greater  or  less  extent  after 
the  age  of  maturity.  This  must  be  especially  true  in  women  who  do  not  achieve 
normal  sexual  gratification  or  in  those  in  whom  the  early  practice  has  by  fixation 
prevented  the  extension  of  sexual  sensibility  from  the  clitoris  to  the  neighboring 
erogenous  zones  (vulva  and  vagina). 

How  often  masturbation  is  acquired  for  the  first  time  after  maturity  it  is 
impossible  to  say,  but  it  may  be  conjectured  that  in  cases  where  gratification  is 
lacking  from  impotence  or  indifference  on  the  part  of  the  husband,  it  is  frequently 
resorted  to  as  a  means  of  relief. 

Hence  we  are  brought  to  the  conclusion  that  after  maturity  onanism  is  more 
common  in  women  than  in  men,  for  in  the  latter  it  is  a  comparatively  rare  habit 
after  the  age  of  twenty-five. 

It  is  a  matter  of  significance  that  the  adult  woman  rarely  consults  a  physician 
for  advice  in  this  matter.  From  this  fact  it  must  be  concluded  that  if  onanism  is 
common  in  the  middle  period  of  life  it  is  not  at  this  time  especially  productive  of 
obvious  harm,  certainly  not  in  comparison  with  the  onanism  of  youth.  There 
is  the  best  authority  for  the  statement  that  the  onanism  of  adult  woman  is  much 
less  detrimental  both  psychically  and  somatically  than  in  adult  man,  Hitsch- 
mann  states  that  "there  is  a  special  sexual  constitution  which  causes  certain 
people  to  become  ill  as  a  result  of  masturbation,  while  others  bear  their  onanism 
without  noticeable  injury."  It  is  important  not  to  depreciate  the  possible  harm 
that  excessive  masturbation  may  do  even  in  matured  Kfe.  The  evil  results  are 
seen  mostly  in  psychoneurotic  reactions  and  are  more  famihar  to  the  neurologist 
than  to  the  gynecologist. 

The  onanism  of  woman,  as  a  rule,  produces  no  observable  somatic  changes, 
yet  in  some  cases  objective  signs  are  definite.  Of  these,  the  most  common  is  a 
lengthening  and  attenuation  of  the  labia  minora.  The  change  is  usually  asym- 
metric. Sometimes  only  one  labium  minus  is  affected.  This  deformity  we  are 
incHned  to  think  is  the  result  of  some  special  onanistic  technic  by  which  the 


138  GYNECOLOGY 

labia  become  gradually  stretched.  It  may,  however,  be  analogous  to  the  length- 
ening and  relaxation  of  the  scrotum  characteristic  of  the  male  masturbator. 
The  severe  vulvitis  from  excessive  onanism  is  described  elsewhere.  Other  so- 
matic changes  are  the  result  of  continued  pelvic  congestion.  There  is  no  doubt 
that  some  of  the  cases  of  severe  menorrhagia  in  young  girls  after  puberty  have 
their  origin  in  masturbation,  though  on  this  point  we  have  had  difficulty  in  our 
personal  experience  in  securing  reliable  data.  In  a  typical  extreme  case  the 
uterus  is  much  enlarged  and  usually  retro  verted.  There  is  a  marked  permanent 
gland  hypertrophy.     Menorrhagia  is  severe  and  prolonged. 

In  an  extreme  case  observed  by  us  of  a  girl  of  ten,  marked  dilatation  of  the 
superficial  venous  capillaries  of  the  thighs  and  lower  abdomen  were  noted.  How 
common  this  is  we  do  not  know,  as  we  have  not  seen  it  mentioned  elsewhere. 

It  is  quite  probable  that  masturbation  may  in  some  cases  be  the  primary  or 
contributing  cause  of  the  frequent  condition  of  varicocele  of  the  broad  ligament  in 
the  same  way  as  in  the  male  it  often  leads  to  scrotal  varicocele. 

Dyspareunia. — Like  masturbation,  dyspareunia  is  a  subject  the  importance 
and  frequency  of  which  has  not  been  adequately  estimated  in  the  study  of  the 
physical  and  mental  welfare  of  woman.  The  word  dyspar€U7iia  is  commonly 
misused  as  a  synonym  for  painful  coitus.  In  its  strict  sense  it  denotes  a  condition 
in  which,  though  the  libido  sexuaHs  is  present,  normal  orgasm  is  not  produced  by 
intercourse.  Dyspareunia  may  be  the  result  of  pain,  but  pain  is  not  a  neces- 
sary accompaniment  and,  except  in  a  certain  class  of  cases,  is  absent.  Sexual 
anesthesia,  frigidity,  and  anaphrodism  are  terms  sometimes  used  equivalent  to 
dyspareunia. 

Sexual  anesthesia  is  used  differently  by  different  authors.  Freud  employs  the  term  as 
we  have  used  it  above  as  synonymous  with  dyspareunia,  i.  e.,  local  inexcitability,  libido  sexu- 
ahs  being  present.  Von  Kraft-Ebing,  on  the  other  hand,  uses  the  term  to  denote  complete 
asexuality,  with  entire  absence  of  libido.  Such  a  definition  imphes  an  organic  affection  of  the 
nerve  centers,  such  as  may  arise  from  disease  of  the  brain  or  spinal  cord,  diseases  of  the  endocrine 
glands,  marasmus,  diabetes,  morphinism,  alcoholism,  and  sexual  abuses.  We  prefer  to  use  the 
expression  in  the  Freudian  sense. 

A  complete  understanding  of  the  causes  of  dyspareunia  would  imply  a  knowl- 
edge of  the  mechanism  of  sexual  excitability.  Such  knowledge  we  unfortunately 
do  not  possess  and  we  must  rely  for  guidance  only  on  certain  vague  theories. 
The  nerve  theory  may  be  briefly  stated  as  follows :  coitus  stimulates  the  sensory 
nerves  of  the  clitoris,  the  vulva,  the  vestibule,  and  the  vagina;  this  stimulus  is 
communicated  to  the  cerebral  cortex  where  it  gives  rise  to  pleasurable  sensations; 
from  the  cerebral  cortex  is  produced  a  reflex  stimulation  of  the  genitospinal 
center,  which  in  turn  excites  a  series  of  reflex  discharges  in  the  genital  oj-gans, 
the  most  notable  of  which  are  the  erection  of  the  clitoris  and  the  ejaculation  of 
the  secretions  of  various  glands. 

Such  an  explanation  is  incomplete,  for  it  does  not  take  into  account  the  in- 
fluence of  the  internal  secretions  of  the  body  which  undoubtedly  play  an  impor- 
tant part  in  the  reactions  of  ah  psychic  emotions.  A  deflnite  connection  between 
sexuahty  and  the  endocrine  glands  is  extremely  probable,  but  not  as  yet  under- 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  139 

stood.  The  ovaries,  at  one  time  thought  to  be  the  very  seat  of  sexuahty,  are  now 
known  to  occupy  a  secondary  position,  while  the  sexual  influence  of  the  other 
glands  of  internal  secretion  is  entirely  problematic.  Freud  emphasizes  the 
importance  of  the  chemical  theory  of  sexuality  and  furnishes  the  following 
hypothesis : 

"Through  the  appropriate  excitement  of  erogenous  zones  as  well  as  through  other  condi- 
tions under  which  sexual  excitement  originates  a  material  which  is  universally  distributed  in 
the  organism  becomes  disintegrated,  the  decomposing  products  of  which  supply  a  specific 
stimuKis  to  the  organs  of  reproduction  or  to  the  spinal  center  connected  with  them.  Such  a 
transformation  of  a  toxic  stimulus  to  a  particular  organic  stimulus  we  are  already  familiar  with 
from  other  toxic  products  introduced  into  the  body  from  without." 

Acknowledging  the  inadequacy  of  both  the  nervous  and  chemical  theories 
of  the  mechanism  of  sexuality  we  s^iall  for  the  sake  of  convenience  adopt  the  fol- 
lowing classification  of  Kisch  of  the  fundamental  causes  of  dyspareunia : 

1.  Insufficient  or  completely  wanting  peripheral  stimulation  of  the  sensory 
nerve  terminals  in  the  female  reproductive  canal.  This  implies  a  failure  of 
conduction  of  the  stimulus  to  the  nerve  centers. 

2.  Inhibitory  influences  proceeding  from  the  cerebral  cortex  whereby  pleasur- 
able sensations  and  perceptions  are  checked. 

3.  Diminution  or  cessation  of  the  excitability  of  the  reflex  center  in  the  spine 
(genitospinal  center).     This  leads  to  failure  of  the  sense  of  ejaculation. 

This  forms  a  workable,  though  from  the  viewpoint  of  the  chemical  theory 
perhaps  not  a  truly  scientific,  classification.  It  may  be  summed  up  by  saying 
that  dyspareunia  may  be  the  result  of  (1)  failure  of  local  sensibihty,  (2)  failure 
of  a  central  pleasure  sensation,  and  (3)  failure  of  discharge. 

Although  we  have  adopted  the  essential  classification  of  Kisch,  we  shall  not 
follow  his  grouping  of  specific  conditions. 

Under  the  first  heading,  i.  e.,  lack  of  local  sexual  sensibility,  we  must  include 
primarily  that  condition  mentioned  above  and  suggested  by  Freud  in  which  the 
clitoris  refuses  to  give  up  its  excitability  to  the  surrounding  erogenous  zones  of 
the  vulva  and  vagina.  Freud,  we  have  seen,  believes  that  this  failure  when 
temporary  is  physiologic  and  usually  ensues  for  a  variable  period  of  time  after 
defloration.  If  the  anesthesia  of  the  vagina  and  vulva  remains  permanent 
Freud  believes  that  it  is  frequently  the  result  of  early  masturbation  by  which  the 
clitoris  as  a  consequence  of  overstimulation  becomes  incapable  of  sharing  its 
power  of  excitation  with  the  neighboring  areas.  It  is  not  unlikely  that  the 
anesthesia  may  persist  in  many  cases  where  there  has  been  no  masturbatic 
agency  and  even  no  clitoris  excitability.  In  such  a  case  it  might  be  impossible 
to  judge  whether  the  anesthesia  were  due  to  a  congenital  sensory  deficiency  of  the 
peripheral  nerves  or  to  some  psychic  inhibition  dating  from  early  childhood 
except  by  a  skilful  and  searching  psycho-analysis.  The  diagnosis  of  such  a 
case  would  be  important,  for  if  the  condition  were  due  to  congenital  nerve 
deficiency  it  would  be  incurable,  whereas  if  it  were  the  result  of  psychic  repression 
it  might  under  proper  treatment  be  cured. 


140  GYNECOLOGY 

Under  heading  2  (t.  e.,  failure  of  a  central  perception  of  pleasure)  there  are 
numerous  specific  causes  for  dyspareunia.  Important  among  these  are  the  cases 
in  which  local  pain  plays  a  part.  Kisch  groups  these  cases  under  heading  1,  but 
it  seems  more  reasonable  to  us  to  classify  them  with  cases  of  psychic  inhibition, 
for  the  sensation  of  pain  arrives  first  at  the  cerebral  cortex  and  checks  the  pleasure 
sensation  which  without  the  pain  would  have  been  perceived.  The  anesthesia 
accompanying  defloration  may  be  entirely  due  to  the  pain  of  breaking  the  hymen, 
for  undoubtedly  full  sexual  sensibility  sometimes  occurs  as  soon  as  the  lacerated 
part  is  entirely  healed,  though  this  is  probably  not  the  rule.  Any  anatomic 
condition  of  the  genital  tract  which  produces  painful  coitus  may  be  a  cause  of 
dyspareunia.  The  most  frequent  of  these  causes  are  pelvic  inflammatory  proc- 
esses of  all  kinds,  acute  or  chronic,  various  inflammations  of  the  vagina,  cicatrices 
of  the  vaginal  wall,  tumors  of  the  pelvis  or  vagina,  inflammation  of  any  part  of  the 
vulva,  especiall}^  Barthohn's  glands,  urethral  caruncle,  cicatrices  of  the  perineum, 
vesicovaginal  and  rectovaginal  fistula,  etc.  The  frequency  with  which  pain  is 
associated  with  dyspareunia  has  led  to  the  misuse  of  the  term  as  equivalent  to 
painful  coitus. 

Closely  connected  with  pain  as  a  cause  of  dyspareunia  is  the  fear  of  pain. 
This  is  a  purely  psychic  inhibition.  The  anesthesia  which  normally  follows  de- 
floration may  be  of  this  nature.  There  is  no  doubt  that  some  of  the  permanent 
cases  of  dyspareunia  are  the  result  of  the  physical  and  mental  shock  induced  by  an 
inconsiderate  partner  at  the  first  coition.  Thus  dyspareunia  is  alhed  to  vagin- 
ismus. 

Other  very  important  causes  of  dyspareunia  are  the  psychic  repressions  in 
the  strict  Freudian  use  of  the  term.  These  are  the  result  of  early  childhood  fixa- 
tions which  may  be  brought  about  in  various  ways.  Thus  some  accidental  sexual 
experience  of  childhood,  the  so-called  sexual  trauma,  may  engender  a  sense  of 
disgust  for  things  sexual  so  profound  and  lasting  as  to  act  as  a  psychic  barrier 
through  life.^  Or  the  fixation  may  be  the  result  of  an  early  psychic  conflict 
with  sexual  impulses  by  which  the  psychic  censor  becomes  permanently  dominant. 

Freud  emphasizes  as  an  important  factor  in  dyspareunia  the  prolonged  at- 
tachment of  a  daughter  to  her  father.  In  these  cases  sexual  sensibiHty  becomes 
permanently  repressed,  and  when  marriage  takes  place  normal  sexuality  cannot 
be  awakened  nor  can  the  psychic  affection  be  transferred  from  father  to  husband. 
More  or  less  serious  neuroses  are  apt  to  ensue.  A  similar  result  often  follows 
long-continued  interdependence  of  a  mother  and  daughter. 

Dyspareunia  may  be  the  temporary  result  purely  of  emotional  inhibitions, 
such  as  grief,  worry,  fear,  indifference  to  or  hatred  of  partner,  etc.  Such  a  condi- 
tion may  be  called  relative  dyspareunia.  In  woman  local  sexual  sensibility  is 
much  more  dependent  on  psychic  affection  than  in  man.  It  sometimes  happens 
that  a  woman  who  in  the  first  years  of  marriage  is  normal  sexually,  later  acquires 
partial  or  complete  anesthesia.     In  the  absence  of  some  organic  disease  or  fiinc- 

^The  effect  of  such  a  sexual  trauma  is  well  told  in  the  popular  story  "The  Dop  Doctor." 


EELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      141 

tional  changes  in  the  endocrine  glands  this  is  in  most  cases  due  to  a  growing  lack 
of  sympathy  between  the  partners. 

Psychic  inhibitory  dyspareunia  is  occasionally  the  result  of  inversion  in  cases 
where  the  homosexual  inclination  is  so  strong  that  normal  coition  is  distasteful. 

Under  the  third  division  of  the  causes  of  dyspareunia  we  group  those  cases  in 
which  local  sensibility  and  psychic  perception  of  pleasure  are  present,  but  where 
from  lack  of  irritability  of  the  genitospinal  center  the  final  orgastic  discharge  is 
not  completed.  This  is  an  extremely  common  complaint  among  women,  and 
one  which  frequently  leads  to  neurotic  disturbance.  In  some  cases  there  is  an 
undoubted  inherent  deficiency  in  the  excitability  of  the  reflex  spinal  center. 
In  a  large  percentage  of  cases,  however,  it  is  the  result  of  incomplete  coition,  such 
as  is  represented  by  coitus  interruptus,  impotence  and  premature  ejaculation 
of  the  male,  various  methods  of  preventing  conception,  etc. 

There  are  certain  pathologic  conditions  in  which  the  local  and  psychic  ir- 
ritability is  intense,  without  the  possibility  of  complete  gratification.  Patients 
suffering  from  this  trouble  are  in  a  continuous  state  of  unsatiated  erethism.  They 
constitute  the  class  of  nymphomaniacs  and  incessant  masturbators  and  are 
subjects  usually  for  the  psychiatrist. 

Dyspareunia  most  commonly  comes  to  the  notice  of  the  gynecologist  as  a 
complaint  of  women  who  seek  relief  from  sterility.  There  is  no  doubt  that  there 
is  some  etiologic  connection  between  the  two  conditions.  Kisch  found  that  in 
69  sterile  women  38  per  cent,  were  dyspareunic,  though  he  does  not  state  whether 
other  causes  of  sterility  were  present.  Although  impregnation  may  take  place 
in  frigid  women,  or  even  in  those  who  have  been  narcotized,  nevertheless  it  is 
probable  that  for  normal  fertihty  full  sexual  sensibility  is  necessary.  Some  of 
the  mechanisms  incidental  to  impregnation  are  purely  sexual  reactions,  such  as 
the  activity  of  Bartholin's  glands,  the  secretion  of  the  cervical  mucous  crypts,  the 
aspirating  movements  of  the  cervix,  and  the  reflexes  of  the  vaginal  canal  by  which 
the  semen  is  retained.  These  mechanisms,  though  not  absolutely  essential  to 
impregnation,  certainly  favor  conception.  They  are  for  the  most  part  inactive  in 
the  dyspareunic  woman. 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE  NEIGHBORING  ORGANS 

The  genitalia  bear  a  close  relationship  to  the  neighboring  pelvic  organs,  both 
physiologically  and  pathologically,  as  would  be  expected  from  their  intimate 
anatomic  proximity.  Under  normal  conditions  the  bladder  possesses  a  firm 
attachment  to  the  anterior  wall  of  the  uterus,  and  the  uterus  rests  directly 
on  the  vertex  of  the  bladder,  so  that  the  movements  of  each  organ  have  an 
important  influence  on  the  position  of  the  other.  The  filling  and  emptying 
of  the  bladder  may  cause  a  difference  of  as  much  as  90  degrees  in  the  direc- 
tion of  the  axis  of  the  uterus,  while  changes  in  the  plane  of  the  uterus  from 
abdominal  pressure  produce  a  corresponding  change  in  the  upper  pole  of  the 
bladder. 


142  GYNECOLOGY 

The  ureters  pass  through  the  parametrial  tissue  close  to  the  sides  of  the 
cervix  and  immediately  underneath  the  uterine  vessels,  so  that  they  are  readily 
influenced  by  pathologic  disturbances  of  the  parametrium,  or  by  uterine  and 
intraligamentary  tumors,  the  effect  of  the  interference  being  transmitted  directly 
to  the  kidneys  with  significant  results.  The  proximity  of  the  ureters  to  the 
uterus  constitutes  one  of  the  most  important  clangers  in  the  performance  of  deep 
pelvic  surgery. 

Behind  the  uterus  lies  the  rectum,  which  when  filled  with  fecal  matter 
may  alter  to  a  considerable  extent  the  position  of  the  uterus,  while  retrodis- 
placements  and  tumors  pressing  on  the  rectal  wall  may  infiuence  in  an  important 
manner  the  rectal  function.  The  rectum  and  intestines  play  a  serious  role  in 
the  pathology  and  symptomatology  of  pelvic  inflammatory  disease,  as  does  also 
the  peritoneum.  The  appendix  is  another  neighboring  organ  which  must  be 
reckoned  with  in  numerous  gynecologic  conditions. 

The  Bladder. — In  association  with  pathologic  changes  of  the  position  of 
the  uterus  the  bladder  may  undergo  marked  dislocations  or  alterations  of  form. 
In  upward  displacement  due  to  pressure  of  a  tumor  below,  the  vertex  of  the 
bladder  is  also  carried  upward,  but  such  a  change  does  not  always  produce 
vesical  symptoms.  Backward  cHsplacement  of  the  uterus  (retroversion,  retro- 
flexion) does  not  greatly  change  the  position  of  the  bladder,  though  there  may 
be  a  slight  drag  at  the  point  of  the  uterovesical  attachment.  This,  however,, 
is  not  sufficient  to  produce  vesical  irritation,  at  least  to  the  extent  formerly 
supposed.  Downward  displacement  or  descensus  of  the  uterus,  on  the  other 
hand,  has  a  very  important  effect  on  the  bladder,  for  this  is  the  chief  factor 
in  the  production  of  cystocele.  Cystocele  not  only  causes  symptoms  of  pelvic 
pressure,  but,  as  it  represents  a  pouch  or  diverticulum  of  the  bladder  which 
cannot  easily  be  evacuated,  the  stagnant  urine  predisposes  the  bladder  mucosa 
to  infection  and  cystitis. 

When  pressed  upon  by  pelvic  tumors  the  bladder  displays  a  remarkable^ 
mobility  and  adaptability  to  new  positions.  Overlying  tumors  may  press  it 
deep  in  the  pelvis,  and  underlying  tumors  may  force  it  far  up  on  the  abdominal 
wall  or  to  one  side,  while  the  pregnant  uterus  may  compress  it  in  the  center  and' 
cause  bilateral  dilatations  of  the  walls.  In  the  presence  of  great  retroperitoneal! 
tumors  the  bladder  may  be  distorted  into  the  most  bizarre  shapes.  In  many 
of  these  cases,  even  of  marked  pressure  or  displacement,  the  bladder  shows  sur- 
prisingly little  evidence  of  irritabifity.  Conditions  of  displacement,  however,, 
predispose  the  bladder  to  infection  and  irritation,  the  effects  of  which  may  be 
clinically  very  important.  During  pregnancy  the  uterus,  if  in  the  forward 
position,  may  produce  frequency  of  micturition  by  pressure  of  the  overlying 
fundus,  while,  if  the  fundus  is  retroflexed,  the  cervix  may  press  on  the  neck  of 
the  bladder  and  cause  interference  with  urination  or  incontinence.  Impacted 
retroflexion  may  so  obstruct  the  vesical  neck  as  to  result  in  complete  retention 
(ischuria  paradoxa) .     At  childbirth  the  general  congestion  of  the  pelvis  in  which, 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      143 

the  bladder  wall  takes  part  predisposes  to  cystitis,  which  is  frequently  excited 
by  the  necessity  of  catheterization.  Injuries  of  the  bladder  are  often  caused  by 
labor,  as  a  result  of  crushing  pressure  against  the  pubes  or  of  rough  instrumen- 
tation, by  which  the  vesicovaginal  septum  is  either  torn  or  suffers  necrosis  with 
consequent  fistula.  The  injury  which  the  bladder  undergoes  during  labor  often 
results  in  damage  to  the  vesical  sphincter,  so  that  it  becomes  incompetent  and 
the  patient  suffers  functional  incontinence. 

In  inflammatory  processes  of  the  genitalia  the  bladder  is  often  imphcated. 
Gonorrheal  pelveoperitonitis,  as  is  mentioned  several  times  elsewhere,  is  usually 
confined  to  the  posterior  segment  of  the  pelvis,  but  it  may  be  so  extensive  as  to 
involve  the  anterior  half  and  the  bladder.  Septic  processes  of  the  different 
pelvic  organs  sometimes  form  adhesions  to  and  rupture  into  the  bladder,  ex- 
amples of  which  are  tubal,  and  ovarian  abscesses,  necrotic  tubal  pregnancies, 
ovarian  dermoids,  and  purulent  diverticula  of  the  sigmoid.  Parametritis  fol- 
lowing supravaginal  hysterectomy  or  a  septic  puerperium  usually  involves  the 
bladder  in  a  temporary  cystitis,  and,  conversely,  extensive  deep-seated  cystitis 
sometimes  involves  the  parametrium. 

Cancer  of  the  vagina  does  not  implicate  the  bladder  until  late  in  the  dis- 
ease, chiefly  because  it  usually  originates  on  the  posterior  wall.  Cancer  of  the 
uterine  cervix,  however,  frequently  extends  to  the  bladder,  though  it  also  in- 
vades the  wall  comparatively  late.  Vesical  and  genital  tuberculosis  are  curiously 
independent  of  each  other,  an  affection  of  either  tract  having  no  tendency  to 
extend  to  the  other. 

There  is  a  vague  relationship  between  genital  psychoneuroses  and  the  func- 
tion of  the  bladder,  but  it  is  not  specific,  and  probably  does  not  differ  from 
nervous  disturbances  from  other  causes. 

Ureters. — The  influence  of  the  genitalia  on  the  ureters  is  exerted  by  dis- 
turbances which  mechanically  compress  or  dislocate  them  so  as  to  interfere  with 
the  normal  flow  of  urine  from  the  kidneys. 

Partial  obstruction  with  hydro-ureter  is  sometimes  seen  in  autopsies  on 
pregnant  women.  This,  according  to  Opitz,  is  not  the  result  of  direct  pressure, 
but  is  thought  to  be  due  to  hyperemia  and  edema  of  the  ureteral  mucous  mem- 
brane. Rarely  parametrial  exudates  result  in  scars  about  the  ureters,  which 
become  constricted  by  the  shrinking  process  of  the  tissue,  with  consequent 
hydro-ureter  or  hydronephrosis. 

The  ureters  are  affected  chiefly  by  the  retroperitoneal  tumors,  such  as  intra- 
ligamentory  fibroids  and  ovarian  cysts,  which,  if  they  reach  any  considerable 
size,  invariably  dislocate  the  ureters  from  their  normal  position,  a  fact  that 
must  be  borne  constantly  in  mind  while  operating  on  these  tumors. 

Cancer  of  the  cervix  ultimately  invades  the  parametrium  and  surrounds 
the  ureters,  sometimes  constricting  or  occluding  them,  but  not  often  invading 
the  ureteral  wall  itself.  This  implication  of  the  ureters  constitutes  one  of  the 
chief  dangers  and  difficulties  in  the  radical  operation  for  cervical  cancer. 


1.44  GYNECOLOGY 

The  ureters  are  often  injured  during  deep  pelvic  operations,  with  resultant 
fistulas. 

Affections  of  the  ureter,  •especially  stone,  often  give  symptoms  of  pain, 
which  are  referred  to  the  peMc  organs,  causing  incorrect  diagnoses  and  iJl- 
judged  operations. 

The  relationship  between  the  genital  organs  and  inflammatory  conditions 
of  the  peritoneum  and  intestines  is  dealt  with  at  length  in  a  special  section  (see 
page  153). 

Rectum  and  Sigmoid.- — The  rectum  must  be  taken  into  account  in  a  great 
many  gynecologic  conditions.  Most  common  of  these  is  the  rectocele  which 
follows  lacerations  of  the  perineum,  and  which  usually  accompanies  prolapse  of 
the  uterus  and  cystocele.  Rectocele  often  interferes  with  proper  defecation, 
and  is  an  annoyance  to  the  patient  on  account  of  the  sense  of  protrusion  from 
the  vagina.  Rectocele  of  itself,  however,  as  a  rule,  causes  few  subjective  symp- 
toms if  the  uterus  and  bladder  are  not  prolapsed.  The  repair  of  rectovaginal 
fistula  and  complete  laceration  of  the  sphincter  is  an  important  department  in 
the  reconstructive  surgery  of  injuries  due  to  childbirth. 

Hemorrhoids  bear  a  very  significant  relationship  to  pregnancy  and  labor. 
The  pressure  and  stretching  to  which  the  sphincter  is  subjected  at  labor  often 
causes  hemorrhoids  or  aggravates  small  ones  already  existing,  leaving  the  veins 
in  a  permanently  enlarged  and  sometimes  fissured  condition.  Laceration  of 
the  perineum  relaxes  the  tissues  about  the  sphincter,  so  that  the  hemorrhoidal 
veins  cease  to  have  proper  support  and  become  permanently  dilated.  Repair 
of  the  perineum  usually  cures  the  hemorrhoids.  Severe  puerperal  parametritis 
may  involve  the  rectum  in  a  manner  to  constrict  its  lumen,  even  to  complete 
occlusion,  as  has  been  reported  in  a  few  cases. 

The  effect  on  the  rectum  of  the  retroverted  uterus  is  a  subject  of  some  con- 
troversy. It  is  often  stated  that  the  retroflexed  uterus  in  the  course  of  time 
becomes  adherent  to  the  rectum.  It  is  not  likely  that  simple  contact  with  the 
peritoneum  covering  the  rectum  causes  adhesions.  It  is  probable,  however, 
that  a  heavy  uterus,  especially  one  containing  a  fibroid  in  its  posterior  wall, 
can  interfere  with  the  normal  rectal  peristalsis,  and  that  the  stasis  thus  pro- 
duced may  cause  an  inflammation  in  the  rectal  wall  which  is  communicated  to 
the  peritoneum.  This  process  may  take  place  as  a  result  of  constipation  even 
when  the  uterus  is  not  retroverted,  a  painful  and  intractable  condition,  termed 
"posterior  parametritis."  It  is  not  unlikely  that  in  some  cases  the  parametritis 
is  primary  and  'causes  a  retroflexion  by  the  traction  of  adhesions  on  the  poste- 
rior wall  of  the  uterus.  Posterior  parametritis,  with  adhesions  between  the 
uterus  and  posterior  uterine  wafl,  is  not  infrequently  caused  by  the  ill-judged 
use  of  pessaries. 

The  relationship  of  the  rectum  to  acute  inflammatory  conditions  of  the 
pelvis  is  detailed  elsewhere.  Suffice  it  to  say  here  that  tubal  and  ovarian 
abscesses  not  infrequently  rupture  into  the  rectum,  causing  fistulas  that  some- 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      145 

times  heal  spontaneously  and  sometimes  remain  permanent.  It  should  also  be 
repeated  that  many  qf  the  pelvic  abscesses  of  the  gonorrheal  and  tubercular 
type  owe  their  severity  to  a  mixed  infection  caused  by  adhesions  to  the  rectum 
and  migration  through  the  rectal  wall  of  intestinal  micro-organisms  into  the 
abscess  cavity. 

Carcinoma  of  the  cervix  in  its  late  manifestations  invades  the  rectum  and 
often  causes  fistulous  openings.  Cancer  of  the  vagina  also  invades  the  rectum, 
but  only  when  in  advanced  stage.  On  the  other  hand,  low  cancer  of  the  rectum 
involves  the  vaginal  wall  comparatively  early. 

In  severe  pelvic  operations,  especially  where  there  are  extensive  adhesions, 
the  rectum  figures  prominently,  for  it  is  very  readity  injured.  Actual  tears  in 
the  rectal  wall  can  usually  be  sewed  up  with  little  difficult}^,  and,  if  care  is  taken, 
do  not  often  result  in  fistulas.  Most  fistulas  occur  after  injuries  which  damage 
the  rectal  wall  only  partially  and  which  escape  the  notice  of  the  surgeon.  If 
gauze  drainage  is  placed  in  contact  with  one  of  these  lesions  a  fistula  is  inevit- 
able. For  this  reason  gauze  should  never  be  used  for  drainage  in  the  abdominal 
cavity.  Postoperative  fistulas  of  the  rectum,  whether  thej^  lead  to  the  abdo- 
men or  vagina,  usually  heal  spontaneously  in  time,  though  not  always. 

The  symptomatology  of  affections  of  the  rectum  gives  the  false  idea  that 
the  lesions  have  their  seat  in  the  genitaha  and  thus  leads  to  wrong  diagnosis. 
This  is  especially  true  of  acute  diverticulitis  of  the  lower  sigmoid  or  upper 
rectum,  which  may  present  a  picture  very  like  that  of  a  tubal  abscess.  The 
pains  of  chronic  colitis  are  often  referred  to  the  tubes  and  ovaries,  and  patients^ 
sometimes  undergo  needless  operations  from  this  mistake. 

Appendix. — The  anatomic  position  of  the  appendix  peculiarly  predisposes 
it  to  complication  in  affections  of  the  pelvic  organs,  especially  those  of  an  in- 
flammatory nature.  Under  normal  conditions,  the  tip  of  the  appendix  usually 
lies  in  the  pelvis,  near  the  right  tube  and  ovary,  while  in  cases  of  ptosis  or  cecum 
mobile  the  appendix  may  lie  completely  in  the  pelvis,  even  so  low  as  the  floor 
of  Douglas'  pouch.  Between  the  base  of  the  appendix  and  the  hilum  of  the 
ovary  there  runs  a  fold  of  peritoneum,  called  the  "appendiculo-ovarian  liga- 
ment," that  is  usually  only  rudimentary  or  not  demonstrable,  but  often  quite 
definite,  in  which  it  has  been  claimed  run  connecting  lymph-channels  between 
the  appendix  and  the  adnexa.     This  lymph  connection  has  been  denied. 

Sympathetic  relationships  between  the  appendix  and  the  pelvic  organs  are 
based  chiefly  on  inflammatory  processes.  Tumors  of  the  ovaries  may  push 
the  cecum  and  appendix  to  abnormal  positions,  and  occasionally,  though  rarely, 
cause  disturbance. 

Severe  inflammations  of  the  tubes  do  not  exhibit  a  special  tendency  to  im- 
plicate the  appendix,  the  result,  doubtless,  of  gravity,  which  is  effective  in  keep- 
ing the  inflammatory  products  in  the  posterior  and  lower  part  of  the  true  pelvis. 
The  appendix,  however,  is  sometimes  involved  in  the  adhesions  of  a  salpingitis. 
In  this  case  the  inflammation  imparted  to  the  appendix  is  external  and  shows 

10 


146  GYNECOLOGY 

microscopically  as  a  peri-appendicitis,  but  there  is  little  danger  from  this  com- 
plication of  causing  an  acute  dangerous  appendicitis.  The  adhesions  which 
form  about  the  appendix  immobilize  it  and  predispose  it  to  later  attacks  of  acute 
appendicitis,  at  the  same  time  causing  symptoms  of  chronic  inflammation. 

On  the  other  hand,  acute  appendicitis  with  purulent  exudate  is  very  prone 
to  involve  the  right  tube  and  even  the  whole  pelvis,  for  gravity  carries  the 
products  of  inflammation  to  the  pouch  of  Douglas  and  is  thus  instrumental  in 
the  infection  of  the  adnexa.  .  In  this  way  acute  purulent  appendicitis  in  young 
girls  often  causes  very  serious  damage  to  the  genital  organs  in  the  adhesions 
and  closure  of  the  tubes,  adhesion  and  retroversion  of  the  uterus,  and  chronic 
thickening  of  the  cortex  of  the  ovaries.  If  the  attack  occurs  before  puberty  or 
in  young  girlhood  it  may  prevent  full  genital  development  and  result  in  infan- 
tilism, with  its  symptoms  of  amenorrhea  or  dysmenorrhea,  neuroses,  and 
sterility.  Acute  appendicitis  occurring  after  maturity  may,  by  its  damaging 
influence  on  the  genitalia,  cause  sterility,  extra-uterine  pregnancy,  and  dis- 
placements of  the  uterus. 

Very  frequently  chronic  appendicitis  and  chronic  salpingitis  are  found 
associated  together,  where  the  two  conditions  have  originated  entirely  inde- 
pendently of  each  other.  Chronic  appendicitis  is  extraordinarily  common  in 
women,  though  it  often  exists  without  any  appreciable  symptoms.  At  least 
60  per  cent,  of  appendices  seen  at  autopsies,  and  removed  as  a  routine  procedure 
during  abdominal  operations,  show  either  gross  or  microscopic  evidences  of 
inflammation.  Some  even  regard  a  certain  amount  of  chronic  inflammation 
of  the  appendix  as  physiologic.  Such  a  theory,  however,  should  not  be  harbored, 
and  the  appendix  must  be  regarded  as  a  dangerous  and  useless  organ  to  be 
removed  as  a  routine  during  those  abdominal  operations  in  which  the  expendi- 
ture of  the  few  extra  minutes  required  for  its  removal  cannot  be  considered  detri- 
mental to  the  patient. 

There  is  a  very  definite  relationship  between  chronic  appendicitis  and 
menstruation.  The  premenstrual  and  menstrual  hyperemia  aggravates  in- 
flammatory conditions  of  the  appendix  region  as  it  does  those  of  the  pelvis,  so 
that  patients  with  chronic  appendicitis  almost  invariably  feel  the  pain  more 
at  the  menstrual  period,  while  many  experience  it  then  and  at  no  other  time. 
Moreover,  attacks  of  acute  appendicitis  often  have  their  starting-point  at  the 
time  of  menstruation. 

The  course  of  appendicitis  during  pregnancy  and  childbirth  is  a  subject  of 
considerable  moment.  It  is  not  probable  that  pregnancy  predisposes  to  an 
initial  infection  of  the  appendix,  but  there  is  no  doubt  that  in  the  presence  of  a 
latent  appendicitis  pregnancy  predisposes  to  recurrent  attacks  or  to  lighting 
up  the  infection  into  one  of  acute  activity.  Numerous  factors  naturally  con- 
tribute to  this  effect.  Stretching  and  pulling  of  a  spiral  or  kinked  appendix 
and  tearing  of  old  adhesions  may  be  caused  by  the  growing  uterus  (Wagner). 
Moreover,  the  increased  constipation  during  pregnancy,  and  the  venous  con- 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  147 

gestion  of  the  pelvis  and  abdominal  organs,  constitute  conditions  favorable  to 
inflammation  of  the  appendix.  In  the  mild  types  of  appendicitis  the  course 
during  pregnancy  does  not  differ  essentially  from  that  seen  in  non-pregnant 
women,  but,  if  perforation  or  suppuration  takes  place,  the  danger  of  fatal 
peritonitis  is  very  much  greater  in  pregnancy.  The  explanation  of  this  is  that 
the  cecum  and  appendix  are  forced  from  the  protected  recess  in  which  they 
normally  lie,  forward  and  upward  into  the  free  abdominal  cavity.  The  omen- 
tum is  prevented  from  performing  its  usual  walling-o£f  service  by  the  interven- 
tion of  the  gravid  uterus,  which  tends  to  keep  it  in  the  left  side  of  the  abdomen. 
The  collection  and  isolation  of  the  inflammatory  products  in  the  pelvis,  which 
is  usual  in  the  ordinary  case  of  acute  appendicitis,  is  impossible  during  preg- 
nancy because  the  pelvis  is  filled  with  the  gravid  uterus.  Hence  it  will  be 
seen  that  the  peritoneum  during  pregnancy  is  especially  exposed  to  general 
infection  from  a  suppurating  process  of  the  appendix. 

Still  more  dangerous  is  an  acute  suppurative  appendicitis  that  occurs  at 
the  time  of  labor,  or  an  appendical  abscess  that  by  its  attachment  to  the  uterine 
wall,  precipitates  a  premature  delivery.  Here  the  sudden  diminution  in  size 
of  the  uterus  and  the  general  change  that  takes  place  in  the  position  of  the  ab- 
dominal organs  rends  the  protecting  adhesions,  and  causes  a  discharge  of  pus 
into  the  free  peritoneal  cavity,  a  disaster  which  surgical  operation  seldom 
remedies. 

In  sum,  it  may  be  said  that  a  chronic  or  subacute  appendicitis  has  during 
pregnancy  a  predisposition  to  become  acute,  and  that  if  suppuration  and  abscess 
formation  or  perforation  take  place  the  danger  of  general  peritonitis  is  consider- 
ably increased  by  pregnancy  and  very  much  increased  by  labor,  whether  it  be 
at  term  or  premature.  Immediate  removal  of  the  appendix  on  suspicion  of 
inflammation  is,  therefore,  always  advisable  during  pregnancy.  It  may  be 
said  that  the  operation  is  only  rarely  followed  by  abortion  if  the  appendix  is  in 
the  catarrhal  or  chronic  stage  of  inflammation. 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE   GALL-BLADDER 

Between  diseases  of  the  pelvis  and  those  of  the  gall-bladder  there  exists  no 
direct  or  indirect  causal  relationship,  excepting  in  the  possible  metastasis  from 
one  region  to  the  other  of  malignant  growths.  There  are,  however,  numerous 
ways  in  which  disturbances  of  the  gall-bladder  require  very  serious  considera- 
tion on  the  part,  of  the  gynecologist.  In  every  routine  abdominal  examination 
the  gall-bladder  must  never  be  overlooked,  especially  when  there  is  any  com- 
plaint of  right-sided  pain  or  of  vague  symptoms  in  the  upper  abdomen.  During 
an  active  attack  of  adnexal  or  gall-bladder  disease  a  differential  diagnosis  is  a 
simple  matter,  but  if  active  pain  is  not  present  at  the  time  of  examination,  and 
the  examiner  must  rely  to  a  great  extent  on  the  story  of  the  patient,  the  dis- 
eases are  not  infrequently  confounded,  notwithstanding  the  comparative  remote- 


148  GYNECOLOGY 

ness  from  each  other  of  the  two  regions.  The  difficulty  often  encountered,  even 
by  the  most  experienced,  in  the  differentiation  of  chronic  disease  of  the  gall- 
bladder and  that  of  the  appendix  is  familiar  to  every  practitioner.  Even  more 
difficult  to  distinguish  from  chronic  affections  of  the  gall-bladder  are  the  con- 
ditions arising  from  the  obstructing  adhesions  to  which  the  ascending  colon 
is  so  frequently  prone. 

The  presence  of  gall-bladder  changes  associated  with  pelvic  disease  is  very 
often  manifested  by  vague  feelings  of  distress  of  the  upper  abdomen  of  the  diges- 
tive character,  which, _  as  Clark  emphatically  states,  must  not  in  an}^  sense  be 
regarded  as  reflex  symptoms  originating  in  the  pelvic  lesion.  Concomitant 
symptoms  of  this  kind  in  gynecologic  cases  must  be  given  much  weight,  a  large 
percentage  of  them  when  properly  interpreted  indicating  the  presence  of  gall- 
bladder disease,  in  contrast  to  affections  of  the  duodenum  and  pylorus  which  in 
gynecologic  practice  are  comparatively  uncommon  (Clark). 

Patients  suffering  from  symptoms  in  the  gall-bladder  region  alone  are  not, 
in  the  strictest  sense,  within  the  sphere  of  gynecology,  nevertheless  they  very 
frequently  consult  the  gynecologist,  who  is  required  to  make  an  accurate  ab- 
dominal diagnosis. 

Of  chief  importance  to  the  pelvic  surgeon  is  the  discovery  of  gall-stones 
during  the  routine  intra-abdominal  examination  which  should  be  made,  when 
feasible,  in  the  course  of  every  pelvic  operation. 

Cases  of  this  kind  may  be  divided  into  two  classes,  those  in  which  the  history 
of  the  patient  gives  more  or  less  evidence  that  the  gall-stones  have  caused  symp- 
toms, and  those  in  which  the  presence  of  the  stones  is  entirely  unexpected.  In 
the  first  class  of  cases  the  treatment  is  obvious,  namely,  appropriate  surgical 
treatment  of  the  gall-bladder  at  the  time  of  the  pelvic  operation,  if  the  conditions 
permit  without  undue  danger,  and  if  such  is  not  the  case,  recommendation  to 
the  patient  of  a  second  operation  at  some  later  date. 

In  the  second  class  of  cases  in  which  the  gall-stones  are  incidentally  found 
without  previously  recognized  symptoms  the  question  of  treatment  is  less 
simple  to  decide,  and  numerous  considerations  must  be  taken  into  account, 
most  important  of  which  is  the  pathologic  significance  of  so-called  symptomless 
cholelithiasis.  The  fallacy  once  held  that  a  large  percentage  of  gall-stones  are 
entirely  innocuous  has  of  late  years  been  exposed,  especially  by  the  work  of 
J.  G.  Clark,  who  in  writing  on  the  subject  has  repeatedly  called  attention  to  the 
fact  that  "in  the  majority  of  cases  of  cholelithiasis  micro-organisms  of  a  more 
or  less  pathogenic  nature  are  found,  and  that  under  these  circumstances  many 
vague  symptoms,  usually  attributed  to  gastro-intestinal  or  general  consti- 
tutional disturbance,  may  arise  as  the  result  of  toxins  elaborated  about  these 
foreign  bodies  (stones)  in  the  gall-bladder." 

In  considering  the  patient's  history,  therefore,  with  a  view  to  the  treatment 
of  incidentally  discovered  gall-stones,  the  absence  of  the  classical  symptoms  of 
gall-stone  attacks  does  not  by  any  means  indicate  that  the  presence  of  the 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      149 

stones  has  been  symptomless.  Our  present  knowledge  of  cholelithiasis  indi- 
cates that  the  affection  should  always  be  regarded  in  a  serious  light,  and  that 
the  removal  of  the  stones  is  at  least  desirable.  The  question  of  immediate 
surgical  interference  during  the  course  of  a  pelvic  operation  must  be  decided 
by  certain  individual  considerations.  The  extra  operation  involves  no  very 
great  hazard,  as  Clark  estimates  the  mortality  of  cholelithotomy  in  a  large 
series  of  cases  at  2  per  cent.  On  the  other  hand,  in  the  type  of  pelvic  opera- 
tions in  which  an  incidental  cholelithotomy  could  be  considered,  namely,  those 
excluding  cancer  of  the  uterus  and  severe  pelvic  inflammation,  the  mortality 
would  be  less  than  1  per  cent.  The  extra  operation  on  the  gall-bladder,  there- 
fore, at  least  doubles  the  risk  of  the  primary  operation  to  which  the  patient 
has  submitted  herself.  This  added  risk  to  the  life  of  the  patient,  small  though 
it  is,  must  not  be  disregarded  by  the  surgeon,  especially  if  the  primary  opera- 
tion has  been  a  severe  one,  or  if  the  patient  has  expressly  stated  that  she  wishes 
to  undergo  no  extra  risk.  Gall-bladder  surgery  entails  a  greater  danger,  both 
of  postoperative  pneumonia  and  of  sepsis,  than  do  the  pelvic  operations  in 
conjunction  with  which  the  gall-bladder  operations  may  be  performed;  more- 
over, there  can  be  no  doubt  that  even  a  simple  cholecystotomy  must  be  more 
dangerous  when  done  conjointly  with  another  abdominal  operation  than  when 
performed  alone.  In  addition  to  the  added  risk  to  life  of  cholecystotomy,  one 
must  also  take  into  account  the  inconvenience  and  possible  loAg  persistence  of 
drainage  from  a  gall-bladder  wound,  which  some  patients  resent  who  have  sub- 
mitted themselves  to  a  minor  pelvic  operation.  It  must  be  remembered,  too, 
that  gall-stones,  though  usually  harmful  to  the  patient's  health,  are,  neverthe- 
less, in  the  majority  of  cases,  not  fatal. 

In  view  of  all  these  considerations,  we  are  rather  conservative  in  the  matter 
of  operating  at  once  on  gall-stones  found  during  a  pelvic  operation  unless  con- 
ditions are  simple,  and  prefer  in  the  greater  number  of  cases  to  state  the  con- 
dition to  the  patient  during  her  convalescence,  and  to  operate  with  her  con- 
sent at  a  later  date  when  she  has  fully  recovered  from  the  primary  operation. 
The  problem  is  greatly  simplified  by  making  it  a  routine  practice  to  explain  to 
the  patient  before  a  pelvic  operation  certain  complicating  conditions  that  may 
be  encountered  unexpectedly,  and  to  gain  consent  to  do  that  which,  in  the 
mind  of  the  surgeon,  will  be  of  greatest  benefit  to  future  health.  With  nervous 
or  ignorant  patients  this  must  be  done  with  tact  in  order  not  to  give  them  un- 
necessary alarm.  With  a  certain  class  of  patients  it  is  advisable  to  have  the 
consent  in  writing. 

The  gall-bladder  should  always  be  examined  as  a  routine  measure  during 
pelvic  operations,  excepting  when  it  is  important  to  make  an  incision  so  small 
as  not  to  admit  the  hand,  or  when  there  is  sepsis  present.  In  the  latter  case 
the  danger  of  spreading  infection  to  the  upper  portions  of  the  peritoneal  cavity 
is  obvious.  Palpation  of  the  gall-bladder  from  a  low  median  incision  requires 
accurate  anatomic  knowledge  of  the  upper  abdominal  region  and  expertness  of 


150  GYNECOLOGY 

touch,  for  it  is  often  difficult  to  differentiate  a  collapsed  gall-bladder  from  a 
loop  of  small  intestine. 

If  gall-stones  are  found,  and  it  is  decided  to  remove  them  at  once,  it  is  a 
temptation  to  perform  the  operation  with  the  left  hand  in  the  abdomen  to 
guide  the  incision  and  to  hold  the  gall-bladder  up  into  the  wound  from  below, 
from  which  position  the  gall-stones  can  be  pressed  out  with  the  greatest  ease. 
This  simple  and  rapid  method  of  doing  the  operation  is,  however,  fraught  with 
danger,  for  it  is  almost  impossible  to  avoid  soiling  the  fingers  with  bile,  so  that 
when  the  hand  is  withdrawn  from  the  lower  wound  there  is  danger  of  infecting 
the  intervening  peritoneum.  The  safest  method  is  to  complete  the  pelvic 
operation  and  to  apply  an  efficient  protective  dressing  to  the  abdominal  wound. 
The  operation  for  gall-stones  is  then  performed  with  every  preparation  as  if  it 
were  the  initial  operation,  especially  with  regard  to  the  position  of  the  patient, 
which  is  important,  for  it  is  not  possible  to  foretell  the  extent  of  the  operation 
until  the  gall-bladder  is  exposed.  The  type  of  operation  must  be  determined 
by  the  surgical  judgment  of  the  operator.  In  the  simplest  cases  the  so-called 
"ideal  operation"  of  removing  the  stones  and  closing  both  the  wound  in  the 
gall-bladder  and  that  of  the  abdomen  involves  some  risks.  A  safer  method 
of  treating  the  very  simple  cases  is  to  close  the  gall-bladder,  but  to  leave  through 
the  abdominal  wound  a  small  cigarette  drain.  The  classic  and  safe  method 
in  the  average  uncomplicated  case  is  to  drain  the  gall-bladder,  the  wound  from 
which  should,  under  right  conditions,  close  in  two  or  three  weeks,  but  unfor- 
tunately the  period  of  closure  is  frequently  considerably  longer  than  this.  When 
complications  are  present,  cholecystectomy  is  the  operation  of  choice,  indications 
for  which  are  changes  in  the  wall  of  the  gall-bladder,  by  which  it  has  become 
thick  and  indurated,  or  thin  and  distended,  or  by  which  the  mucosa  has  under- 
gone ulcerative  and  inflammatory  processes.  Chronic  inflammation  of  the 
mucous  membrane  is  manifested  by  the  well-known  "strawberry  mottling" 
appearance.  Adhesions  about  the  gall-bladder  and  stricture  of  the  cystic 
duct  are  other  indications  for  cholecystectomy.  A  discussion  of  the  more 
serious  complications  of  the  hepatic  and  common  ducts  does  not  properly  come 
within  the  sphere  of  this  book. 

RELATIONSHIP    OF    GYNECOLOGY    TO     THE    PERITONEUM    AND 

OMENTUM! 

A  knowledge  of  the  physiology  and  pathology  of  the  peritoneum  is  of  ex- 
treme importance,  for  not  only  is  a  large  part  of  the  symptomatology  of  pelvic 
disease  referable  to  affections  of  the  peritoneum,  but  it  is  on  its  natural  plastic 
properties  that  the  surgeon  depends  for  some  of  his  reconstructive  operations. 

The  free  surface  of  the  peritoneum  consists  of  a  single  layer  of  flat  polj^gonal 
epithelial  cells,  filled  with  a  fine  granular  protoplasm.     These  cells  are  held 

^  Chief  authority,  Fromme. 


RELATIONSHIP    OF    GYNECOLOGY   TO    THE    GENERAL    ORGANISM  151 

together  by  delicate  fibrils,  which,  by  their  elasticity,  allow  the  peritoneal  layer 
to  adapt  itself  continually  to  the  changes  in  size  of  the  hollow  organs  which  it 
encompasses. 

Between  the  epithelial  cells  are  numerous  small  openings  or  stomata  through 
which  t»he  lymph-vessels  empty  into  the  periton.eal  cavity.  Each  small  open- 
ing is  surrounded  by  epithelial  cells  arranged  in  a  somewhat  concentric  order, 
the  power  of  contraction  of  which  probably  controls  the  size  of  the  stoma. 

Under  the  surface  epithelium  hes  the  subserosa,  which  consists  of  bundles 
of  connective  tissue,  elastic  fibers,  and  fat.  In  this  tissue  runs  a  rich  network 
of  communicating  lymph-vessels,  besides  blood-vessels  and  nerves.  The  lymph- 
vessels  of  the  peritoneal  and  pleural  cavities  communicate  by  perforating  the 
diaphragm. 

The  nerves  of  the  peritoneum  he  in  the  subserous  layer  and  are  not  particu- 
larly numerous.  It  has  been  shown  that  the  parietal  peritoneum  is  much  more 
sensitive  than  that  covering  the  viscera,  due  to  the  communication  which  its 
serosa  has  with  the  intercostal,  lumbar,  and  sacral  nerves.  Between  the  muscu- 
lar layers  of  the  intestines  there  runs  a  rich  network  of  sympathetic  nerves,  with 
many  microscopic  gangha,  the  so-called  "Auerbach's  plexus,"  which  plays  a 
very  important  part  in  the  intestinal  paralysis  of  peritonitis,  ileus,  etc.  Under 
normal  conditions  the  production  and  absorption  of  fluid  is  so  regulated  that 
the  peritoneal  surface  is  kept  sufficiently  moist  to  provide  for  perfect  lubrication 
for  the  movements  of  the  various  organs,  but  under  pathologic  conditions  the 
power  of  the  peritoneum,  both  for  production  of  fluid  and  its  absorption,  is 
enormous. 

The  surface  of  the  peritoneum  is  very  great  and  is  said  to  equal  that  of  the 
outside  of  the  body.  This  great  extent  of  absorbing  surface  is  of  advantage  in 
taking  care  of  the  products  of  mild  infections,  such  as  frequently  ensue  after 
operation,  but  is  a  source  of  danger  when  the  infection  spreads  over  a  large  part 
of  the  area,  in  which  case  so  much  toxic  material  is  absorbed  that  the  resisting 
power  of  the  individual  is  overcome.  To  counteract  the  tendency  of  infec- 
tions to  spread  over  the  entire  abdominal  cavity  is  the  anatomic  arrangement 
by  which  the  cavity  is  divided  into  numerous  sacs,  which,  though  communi- 
cating with  each  other  normally,  are,  when  infected,  readily  isolated  by  adhe- 
sions. The  isolation  and  exclusion  of  these  various  sacs  or  pockets  of  which 
the  true  pelvis  is  the  most  notable  example  is  greatly  facilitated  by  the  great 
omentum  and  the  movable  portions  of  the  colon,  especially  by  the  sigmoid 
flexure,  less  often  by  coils  of  the  small  intestine. 

The  omentum  is  of  inestimable  benefit  in  the  walling  off  and  localization 
of  infection.  On  account  of  its  length  and  mobility  it  is  able  ordinarily  to  reach 
any  portion  of  the  abdominal  cavity,  and  in  most  cases  of  locahzed  peritoneal 
infection  the  omentum  will  be  found  doing  a  large  share  of  protective  duty. 
Its  adhesive  power  is  enhanced  by  its  endowment  with  four  peritoneal  layers- 
two  on  the  outer  surfaces  and  two  toward  the  omental  bursa.     The  omentum 


152  GYNECOLOGY 

is,  therefore,  exceedingly  well  supplied  with  blood-  and  lymph-vessels,  and  can 
furnish  a  greater  amount  of  serum  and  phagocytes  than  can  the  rest  of  the 
peritoneum.  Thus  it  is  an  important  protective  organ  against  infection,  as 
has  been  proved  by  experimentation,  in  which  it  has  been  shown  that  animals 
from  whom  the  omentum  has  been  radically  removed  are  much  less  resistant  to 
peritoneal  infection  than  are  normal  control  animals. 

The  omentum  besides  its  protective  power  also  has  a  corresponding  absorb- 
ing power,  greater  than  that  of  the  rest  of  the  peritoneal  cavity.  In  addition 
to  this,  it  has  the  astonishing  ability  to  fasten  itself  to  organs  that  have  been 
bereft  of  their  circulation,  establish  a  new  communication  of  blood-vessels,  and 
thus  nourish  the  organ  or  prevent  its  being  infected.  A  good  example  of  this 
is  the  way  in  which  parasitic  fibroids  that  become  detached  from  the  wall  of 
the  uterus  are  nourished  and  kept  ahve  by  the  protecting  care  of  the  omentum. 

The  omentum  is  also  of  great  use  in  surgical  operations  for  the  plastic  cover- 
ing up  of  defects  in  tissues,  such  as  extensive  denudations  after  the  removal 
of  adhesions.  It  has  been  shown  by  experimentation  that  when  a  piece  of 
omentum  is  transplanted  to  a  denuded  surface  a  communication  of  blood-vessels 
between  the  two  takes  place  on  the  second  day. 

Another  very  important  service  that  the  omentum  performs  is  its  capacity 
to  shp  into  defects  of  the  abdominal  wall  and  thus  prevent  the  entrance  of  the 
intestine.  In  most  ventral  hernias  it  is  most  effective  in  preventing  involve- 
ment and  injury  of  the  bowel.  In  inguinal  hernias  the  same  is  true  whenever 
the  omentum  is  long  enough  to  reach  the  opening.  In  penetrating  wounds  of 
the  peritoneum  the  omentum  by  its  extraordinary  mobility  and  lability  often 
enters  the  wound  first  and  prevents  the  prolapse  of  the  intestine. 

The  peritoneum  has  a  special  protective  characteristic  in  that  it  is  not 
easily  penetrated  by  external  infection.  Subperitoneal  abscesses,  such  as  occur 
in  abdominal  wounds  or  in  the  parametrium,  do  not  often  extend  into  the 
peritoneal  cavity.  This  is  partly  due  to  the  fact  that  it  possesses  a  remark- 
able power  of  elasticity  and  offers  little  resistance  to  the  pressure  of  the  abscess. 
The  peritoneum  also  has  an  unusual  reparative  power  of  its  epithelium,  denuded 
surfaces  being  rapidly  covered  by  newly  grown  cells. 

Transudation  and  Resorption. — As  has  been  said,  there  exists  between 
the  contiguous  peritoneal  surfaces  only  a  capillary  layer  of  free  fluid  which  is 
just  enough  to  keep  the  surfaces  well  lubricated.  This  fluid  is  continually  being 
renewed  and  absorbed  by  the  subserous  circulatory  apparatus  already  described. 
When,  however,  there  is  any  irritation  of  the  peritoneum  an  increased  amount 
of  the  fluid  issues  in  the  form  of  a  serous  exudate.  The  epithelial  cells  become 
swollen  and  cloudy.  A  fatty  granular  degeneration  takes  place  in  the  proto- 
plasm, and  there  follows  in  places  a  destruction  and  denudation  of  the  epithelium. 

After  the  partial  destruction  of  the  surface  epithelium  the  same  irritat- 
ing influence  also  injures  the  walls  of  the  underlying  capillaries,  thereby  creat- 
ing a  greater  permeability  for  the  passage  of  the  exudate  and  a  chemical  change 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      153 

in  the  constituents  of  the  blood.  Together  with  the  exudate,  there  takes  place 
an  outward  wandering  of  leukocytes  by  diapedis.  Fibrin  coagulation  takes 
place  in  the  exudate.  The  exudate  probably  has  httle  bactericidal  action,  but 
its  function  is  probably  to  dilute  the  injurious  toxins  of  the  irritant,  and,  still 
more  important,  to  pour  into  the  peritoneal  cavity  a  rich  supply  of  leukocytes. 

Absorption  of  fluid  material  in  the  peritoneal  cavity  is  carried  out  by  the 
subserous  blood  and  lymph  capillaries.  If  the  absorbed  material  is  toxic,  its 
influence  then  is  met  by  the  general  resisting  power  of  the  body,  which  is  suffi- 
cient to  neutralize  a  moderate  amount  of  absorption.  If,  however,  the  toxins 
absorbed  are  too  great  in  amount  or  too  virulent  for  the  general  resistance  to 
withstand,  the  individual  succumbs.  The  combat  against  bacterial  infection 
is  also  carried  on  by  the  phagocj^tic  power  of  the  leukocytes  contained  in  the 
exudate. 

Adhesions. — From  the  standpoint  of  the  gynecologist  the  most  important 
reaction  that  takes  place  from  peritoneal  irritation  from  whatever  cause  is  the 
formation  of  protective  adhesions.  Adhesions  are  the  result  primarily  of 
injury  to  and  destruction  of  the  epithelial  layer  of  two  contiguous  surfaces.  When 
the  serous  surfaces  are  denuded  the  connective-tissue  subserous  layers  become 
united  by  fine  strands  of  fibrin  into  which  stream  wandering  cells  (fibroblasts), 
so  that  eventually  a  true  connective-tissue  union  is  created.  Adhesions  com- 
petent to  withstand  the  pressure  of  fluid  and  prevent  the  spread  of  infection 
may  form  within  a  few  hours.  In  the  early  stages  adhesions  are  filmy  and 
easily  broken  up  by  the  hand,  but  as  time  goes  on  they  become  more  organized 
and  denser  and  gradually  contract  in  the  manner  of  scar  tissue.  The  eventual 
character  and  fate  of  adhesions  depends  somewhat  on  the  nature  of  the  cause 
which  originally  produced  them. 

Thus,  we  see  that  whatever  produces  a  destruction  of  the  peritoneal  epi- 
thelium causes  also  the  formation  of  adhesions. 

The  surface  epithelium  of  the  peritoneum  may  be  destroyed  (1)  by  bac- 
terial infection;  (2)  by  chemical  injury;  (3)  by  mechanical  insults,  and  (4)  by 
surface  necrosis  due  to  local  interference  of  the  blood  supply.  These  may, 
therefore,  be  regarded  as  the  four  chief  causes  of  peritoneal  adhesions. 

(1)  Bacterial  Peritonitis. — From  the  standpoint  of  gynecology  we  are  inter- 
ested principally  in  those  forms  of  peritonitis  which  are  confined  chiefly  to  the 
pelvis,  and  of  these  the  most  important  is  that  which  results  from  gonorrhea. 
Gonorrheal  peritonitis  ascends  from  a  primary  infection  of  the  external  genitals 
and  extends  through  the  tubes  to  the  pelvic  peritoneum.  In  the  great  majority 
of  cases  the  inflammatory  process  is  confined  to  the  posterior  half  of  the  pelvis, 
and  it  is  in  this  region,  therefore,  that  we  find  the  principal  adhesions.  The 
surface  of  the  tubes  and  ovaries  is  the  first  to  be  affected,  so  that  the  earliest 
adhesions  form  between  them  and  the  posterior  aspect  of  the  broad  ligament 
against  which  they  naturally  rest.  If  the  disease  progresses  adhesions  form, 
uniting  the  posterior  surfaces  of  the  adnexa  and  uterus  with  the  rectum  and 


154  GYNECOLOGY 

sigmoid  or  other  portion  of  bowel  that  may  have  prolapsed  into  the  true  pelvis. 
The  contraction  of  the  adhesions  draws  the  pelvic  organs  backward  and  down- 
ward deep  into  the  posterior  and  lateral  culdesacs.  The  disease  is  locahzed 
in  the  pelvis  partly  by  gravity  and  partly  by  the  protecting  services  of  the 
great  omentum  and  the  sigmoid  flexure,  which,  as  a  rule,  prevent  the  infection 
from  spreading  above  the  brim  of  the  pelvis.  Adhesions  from  gonorrheal  peri- 
tonitis have  little  tendency  to  become  absorbed,  but  rather  grow  denser  and 
tougher  with  time.  They  are  also  notable  for  their  contractile  power  and  result 
in  serious  displacements  of  organs. 

Infection  of  the  pelvic  organs  by  puerperal  sepsis  results  in  fewer  adhe- 
sions than  does  that  from  gonorrhea,  and  for  that  reason  it  is  less  hkely  to  be 
confined  to  the  pelvis,  and  much  more  frequently  extends  to  the  general  ab- 
dominal cavity,  causing  a  diffuse  peritonitis  and  death.  Such  cases  are  usually 
due  to  the  streptococcus,  the  virulence  of  which  is  so  great  that  time  is  not 
given  to  the  plastic  apparatus  of  the  peritoneum  to  form  protective  adhesions 
before  a  fatal  dose  of  toxins  is  absorbed. 

Other  organisms  than  the  streptococcus  may  infect  the  pelvic  organs  from 
puerperal  sepsis,  chief  among  these  being  the  staphylococcus  group. 

A  third  common  form  of  adhesions  from  bacterial  peritonitis  is  that  which 
is  produced  by  tuberculosis,  the  invasion  of  which  takes  place  .either  by  con- 
tinuation from  a  general  abdominal  peritonitis  or  through  the  blood-current 
from  some  distant  focus,  usually  in  the  lungs  or  lymph-glands.  The  adhesions 
resulting  from  tuberculosis  are  often  extremely  dense  and  vascular,  so  that  it 
may  be  impossible  to  separate  them  without  causing  serious  damage  to  the 
organs  which  they  involve.  Tubercular  adhesions,  even  the  most  resistant, 
have  the  peculiarity  of  often  being  completely  absorbed,  a  characteristic  which 
is  not  seen  in  adhesions  due  to  gonorrhea. 

(2)  Adhesions  due  to  chemical  injury  are  comparatively  uncommon.  The 
irritation  and  adhesions  from  bile  spilled  in  the  peritoneal  cavity  is  an  example 
of  this,  as  proved  by  the  results  of  injecting  sterile  bile  into  the  abdomens  of 
animals.  Another  example  is  the  adhesive  peritoneal  irritation  seen  in  pesudo- 
myxoma  peritonei.  Doubtless  the  adhesions  from  uninfected  blood-clots  in 
the  pelvis,  such  as  sometimes  result  from  tubal  abortion,  have  their  origin  in 
the  chemical  irritation  of  the  disintegrating  blood.  An  excellent  example  of 
chemical  injury  is  the  peritoneal  adhesions,  which  occur  after  oil  has  been  left 
in  the  abdomen  under  the  mistaken  idea  that  oil  will  prevent  adhesions. 

(3)  Adhesio7is  due  to  mechanical  injury  are  the  result  of  a  mechanical  de- 
struction of  the  peritoneal  epithehum,  by  which  two  damaged  contiguous  sur- 
faces become  united  in  the  manner  described  above.  As  a  pathologic  lesion 
this  is  most  commonly  seen  in  some  of  the  adhesions  that  form  on  large  tumors, 
where  the  destruction  of  the  peritoneal  epithelium  is  due  to  pressure  necrosis. 

Traumatic  adhesions  resulting  from  injuries  to  the  peritoneum  during  surgi- 
cal operations  are  included  in  this  group,  though  it  is  not  always  possible  to 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      155 

state  whether  certain  postoperative  adhesions  result  from  trauma  or  from 
mild  sepsis.  There  is  no  doubt  that  the  leaving  of  raw  surfaces  or  ragged  wound 
edges. is  usually  followed  by  adhesions.  Clumsy  protruding  catgut  knots  may 
also  be  followed  by  the  same  result.  Other  traumatic  causes  of  adhesions  are 
rough  handling  of  the  intestines,  improper  use  of  dry  gauze  and  abdominal 
retractors,  too  long  exposure  to  the  drying  influence  of  the  air,  etc. 

One  of  the  most  important  matters  in  the  consideration  of  traumatic  adhe- 
sions is  the  artificial  creation  of  them  for  the  purpose  of  making  new  ligamentous 
supports  for  prolapsed  organs.  Here  the  knowledge  of  the  physiologic  process 
of  adhesion  formation  is  of  great  practical  value  to  the  surgeon,  for  without  an 
appreciation  of  this  process  many  of  his  reconstructive  operations  are  sure  to 
result  in  failure. 

We  know  that  the  approximation  of  two-  epithehal  surfaces  will  not  result 
in  adherence  unless  the  surfaces  are  first  denuded  or  destroyed.  This  is  as  true 
of  the  peritoneum  as  it  is  of  the  skin  or  of  mucous  membrane.  If,  therefore, 
it  is  desired  to  create  a  permanent  hgamentous  attachment  between  two  peri- 
toneal surfaces,  one  must  be  sure  to  destroy  the  epithehum  of  both  surfaces  over 
the  area  of  desired  adhesion.  The  contiguous  serous  surfaces  may  be  denuded 
or  scarified  or  destroyed  by  the  pressure  of  a  very  tight  knot.  , 

The  most  common  practical  appHcation  of  this  principle  is  in  performing 
the  operation  for  ventral  fixation  or  suspension.  The  old-fashioned  method  of 
doing  this  operation  was  to  place  several  stitches  through  the  posterior  wall  of  the 
uterus  and  the  abdominal  wall,  and  to  scarify  or  denude  the  opposing  peritoneal 
surfaces.  This  resulted  in  an  extensive  adhesion,  which  bound  the  uterus  so 
closely  to  the  abdominal  wall  as  to  immobihze  it  completely  and  lead  to  serious 
danger  in  later  childbirth.  The  so-called  "ventrosuspension  operation"  was  done 
by  uniting  the  peritoneal  surfaces  by  a  hght  tie.  A  frequent  result  of  this 
operation  was  a  complete  healing  of  the  peritoneum  without  the  formation  of 
an  adhesion,  or  the  adhesion  might  be  very  slight,  so  that  the  drag  of  the  uterus 
drew  the  abdominal  peritoneum  out  into  a  long  filament,  causing  danger  of 
entanghng  the  bowel  in  an  obstruction. 

The  success  of  the  Gilham  type  of  operation  depends  eventually  on  the  adhe- 
sions which  form  between  the  round  ligaments  and  the  peritoneum  at  the  point 
of  penetration. 

The  success  of  Olshausen's  operation  is  dependent  on  tying  the  suture 
attaching  the  round  hgament  to  the  abdominal  wall  so  tightly  that  the  peritoneal 
epithehum  included  in  the  knot  will  be  destroyed.  If  the  tie  is  too  loosely  made, 
as  is  done  by  the  use  of  catgut  or  animal  tendon,  there  is  danger  of  not  creating 
a  permanent  connective-tissue  ligamentous  adhesion. 

(4)  Adhesions  Due  to  Surface  Necrosis.— This  form  of  adhesions  is  best 
illustrated  by  the  adherence  of  tumors  with  twisted  pedicles  to  the  peritoneal 
surface  of  surrounding  organs.  In  this  case  interference  of  the  blood-supply  to 
the  serous  surface  of  the  tumor  is  caused  by  torsion  of  the  pedicle,  with  conse- 


156  GYNECOLOGY 

quent  destruction  and  necrosis  ot  the  endothelial  cells.     The  same  result  may 
follow  interference  of  the  circulation  of  the  peritoneum  from  any  other  cause. 

The  possibility  of  adhesion  formation  from  transmigration  of  micro-organ- 
isms through  the  intestinal  wall  as  a  result  of  stasis  is  discussed  in  the  section 
on  Intestinal  Adhesive  Bands  {q.  v.). 

RELATIONSHIP  OF  GYNECOLOGY  TO  THE   BONES   AND   JOINTS 

Between  the  pelvic  organs  and  diseases  of  the  bones  and  joints  there  is 
from  the  gynecologic  standpoint  no  frequent  direct  relationship,  if  we  exclude 
the  influence  of  deformed  pelves  on  childbirth,  a  subject  which  does  not  come 
within  the  sphere  of  this  book. 

It  seems  to  be  well  established  that  osteomalacia  is  to  a  certain  extent 
dependent  on  abnormal  ovarian  secretion,  as  is  shown  by  the  marked  improve- 
ment in  the  disease  following  the  operation  of  castration.  Fehling,  who  dis- 
covered the  relationship  of  osteomalacia  to  the  ovaries,  noted  that  women  with 
osteomalacia  exhibit  a  fertility  that  is  double  the  normal.  This  disease  is  also 
shown  to  be  much  more  common  in  woman  than  in  man. 

The  effect  of  the  ovarian  secretion  in  the  development  of  the  skeleton  has 
already  been  described  on  page  51  in  discussing  the  effect  of  early  castration. 

If  enteroptosis  and  nephroptosis  be  included  in  gynecology,  the  causal  rela- 
tionship between  these  conditions  and  the  body  form  is  of  immense  importance, 
as  is  pointed  out  in  the  sections  devoted  to  those  subjects. 

The  gynecologist  is  continually  being  consulted  by  patients  who  refer  their 
bodily  pains  to  disturbances  of  their  pelvic  organs,  whereas,  in  reality,  they  are 
due  to  some  orthopedic  affection.  This  is  pre-eminently  true  of  patients  who 
suffer  with  backache.  The  backache  resulting  from  sacro-iliac  strain  is  some- 
times very  like  that  from  retroflexion,  both  in  character  and  position,  and  can 
with  difficulty  be  differentiated  from  it.  The  same  is  true  of  muscular  strains  in- 
volving the  sacral  and  lower  lumbar  region.  Backache  above  the  lower  lumbar 
and  sacral  region  is  never  pelvic  in  origin,  yet  the  idea  that  uterine  displace- 
ments cause  all  forms  of  backache  is  so  prevalent  that  patients  are  very  prone 
to  ascribe  pain  at  any  segment  of  the  spinal  column  to  pelvic  trouble.  The  same 
is  true  of  patients  with  foot  strain,  whose  chief  symptoms  are  felt  in  the  back 
or  thighs.  The  gynecologist  must,  therefore,  be  continually  on  the  lookout  for 
these  cases,  and  to  avoid  needless  treatment  and  operations  where  the  sym- 
toms  are  in  reality  from  some  orthopedic  origin. 

The  postoperative  treatment  of  gynecologic  patients  often  requires  an 
appreciation  of  orthopedic  principles,  especially  in  providing  proper  abdominal 
supports.  Patients  with  incorrect  body-form  require  the  "remodeling"  of 
the  orthopedist,  especially  after  operations  for  ptosis  and  abdominal  hernia. 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      157 

RELATIONSHIP  OF  GYNECOLOGY  TO  ACUTE  INFECTIOUS  DISEASES 

Acute  infectious  diseases,  outside  of  pregnancy  and  the  puerperium,  affect 
the  genital  system  only  occasionally.  The  most  common  complication  follow- 
ing these  diseases  is  an  acute  septic  vaginitis,  which  may  extend  to  the  cervix 
and  uterine  mucosa.  This  occurs  mostly  in  children  and  may  follow  typhoid, 
cholera,  pneumonia,  variola,  measles,  scarlatina,  and  influenza.  The  vagini- 
tis is  often  very  severe,  and  may  terminate  in  gangrene  and  sloughing  of  the 
entire  canal.  These  severe  inflammations  may  result  in  plastic  adhesions  of  the 
vaginal  surfaces,  causing  a  partial  or  complete  atresia.  The  vaginitis  and  plastic 
union  of  the  walls  may  take  place  without  attracting  attention  to  the  local  dis- 
ease, so  that  nothing  may  be  known  of  its  existence  until  delayed  puberty  with 
symptoms  of  obstructed  menses  make  the  condition  evident.  Many  cases  of 
atresia  formerly  thought  to  be  congenital  or  the  probable  result  of  accidental 
gonorrheal  infection  are  doubtless  traceable  to  one  of  the  acute  infectious  dis- 
eases contracted  in  childhood. 

The  cause  of  infection  of  the  vagina  is  not  always  clear,  as  the  specific 
organisms  of  the  primary  constitutional  disease  cannot  usually  be  demon- 
strated in  the  vaginal  secretions.  It  is  probable  that  the  resistance  of  the 
individual  is  so  reduced  that  the  vagina  no  longer  exerts  its  normal  bactericidal 
action,  and  the  flora  of  the  vulva  find  in  the  vagina  a  favorable  seat  for  ascend- 
ing infection.  The  organisms  found  in  the  vaginal  discharge  are  usually  of  the 
streptococcus,  staphylococcus,  and  colon  bacillus  varieties. 

Occasionally,  though  not  often,  the  tubes  may  be  infected  by  the  specific 
organisms  of  acute  infectious  disease,  notably  typhoid,  pneumonia,  and  in- 
fluenza. It  is  probable  that  the  organisms  in  such  cases  reach  the  tubes  through 
the  circulation. 

Disturbances  of  menstruation  are  very  common  during  the  attack  of  infec- 
tious disease,  the  irregularitj^  consisting  of  too  frequent  and  profuse  flow.  After 
typhoid  there  is  apt  to  be  a  period  of  amenorrhea  and  atrophy  for  a  few  months. 

During  typhoid  fever  there  may  be  a  selective  destruction  of  the  primordial 
and  Graafian  follicles  of  the  ovary,  a  process  which  may  be  so  extensive  as  to 
result  in  the  death  of  all  the  follicles,  with  consequent  atrophy  of  the  ovaries, 
amenorrhea,  and  sterility  (Stolz).  Whether  this  effect  on  the  parenchyma 
of  the  ovary  is  the  result  of  the  typhoid  bacillus  circulating  in  the  blood,  or 
whether  it  is  accomplished  by  a  toxin,  is  not  known. 

Diphtheria  may  occur  secondarily  or  primarih^  in  the  vagina.  It  produces 
ulceration  and  possible  gangrenous  sloughing,  with  ultimate  atresia. 

Influenza  affects  the  genital  organs  in  a  considerable  percentage  of  cases, 
chiefly  in  the  way  of  causing  irregular  menses.  Menstruation  is  often  brought 
on  at  the  beginning  of  the  attack,  even  in  individuals  who  have  had  long-stand- 
ing amenorrhea.  The  menstrual  disturbance  may  appear  as  a  menorrhagia, 
but  very  frequently  as  a  metrorrhagia.    The  uterus  in  these  cases  is  found  to  be 


158  GYNECOLOGY 

large  and  boggy.  It  is  characteristic  that  the  metrorrhagia  caused  by  in- 
fluenza may  last  a  long  time  after  the  influenza  has  disappeared  and  be  exceed- 
ingly intractable. 

Influenza  may  also  cause  certain  acute  infections  of  the  pelvic  organs,  among 
which  there  have  been  described  cases  of  salpingitis,  parametritis,  urethritis, 
and  cystitis.  Gonorrheal  infections  of  the  pelvic  organs  are  often  hghted  up 
into  new  activity  by  an  attack  of  influenza. 

It  has  been  shown  also  that  pelvic  tumors,  such  as  cancers,  uterine  fibroids, 
and  ovarian  cystomata,  sometimes  undergo  a  rapid  enlargement  during  an 
infection  of  influenza. 

Malaria  may  also  cause  a  metrorrhagia,  and  it  has  been  observed  that  the 
metrorrhagia  may  share  in  the  periodicity  of  the  disease  appearing  at  a  certain 
time  each  day. 

It  may  be  said,  in  general,  that  as  a  consequence  of  any  acute  general 
infection  there  may  ensue  a  period  of  amenorrhea,  with  atrophy  of  the  ovaries, 
uterus,  external  genitals,  and  breasts.  This,  however,  is  usually  a  temporary 
manifestation  unless  there  has  been  some  specific  destruction  of  the  ovarian 
follicles,  and  disappears  when  the  patient  has  regained  her  normal  health  and 
strength. 

ENTEROPTOSIS 

Although  there  is  no  very  definite  relationship  between  diseases  of  the  pelvic 
organs  and  enteroptosis,  nevertheless  the  latter  condition  is  so  common  in 
women  and  so  often  associated  with  asthenic  relaxation  of  the  genital  apparatus 
that  it  comes  almost  constantly  to  the  notice  of  the  gynecologist. 

Enteroptosis  relates  to  a  dovv^nward  displacement  of  certain  portions  of  the 
digestive  tract  owing  to  an  inadequacy  of  the  natural  supports,  while  other 
portions  remain  fixed.  In  this  way  the  intestine  becomes  kinked  at  the  points 
of  firmer  attachment,  with  consequent  partial  obstruction  to  the  normal  flow 
of  intestinal  contents.  The  retardation  of  the  intestinal  function  is  termed 
"intestinal  stasis,"  and  results  in  certain  characteristic  digestive  and  constitu- 
tional symptoms. 

The  etiology  of  enteroptosis  is  at  present  beheved  to  be  referable  primarily 
to  congenital  defects  in  certain  attachments  of  the  alimentary  canal  which  are 
normally  supplied  by  nature  in  man  alone  to  support  the  abdominal  organs  on 
account  of  his  erect  posture.  In  addition  to  the  primary  cause  of  congenital 
deficiency  of  supporting  attachments  are  other  predisposing  causes,  namely, 
those  resulting  from  inborn  or  acquired  changes  in  the  body-form  of  the  indi- 
vidual, from  the  loss  of  subperitoneal  fat,  and  from  a  deficiency  in  the  muscular 
force  of  the  abdominal  musculature.  The  supporting  attachments  of  the  viscera 
with  which  man  is  endowed  in  contradistinction  to  quadrupeds  represent  the 
fusion  of  certain  peritoneal  surfaces  that  takes  place  during  the  prenatal  de- 
velopment of  the  intestinal  tract,  and,  as  Coffey  remarks,  are  undoubtedly 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  159 

"for  the  purpose  of  holding  the  organs  in  their  places,  thus  to  prevent  them 
from  piling  up  in  the  bottom  of  the  abdominal  cavity  by  gravity," 
To  quote  Coffey  further: 

"In  studying  the  abdominal  cavity  from  the  standpoint  of  comparative  anatomy  we  find 
that  in  rnan  the  hver  has  fused  with  the  diaphragm,  while  in  the  quadruped  it  is  suspended  by  a 
mesentery  the  same  as  other  organs.  In  man  the  duodenum  is  firmly  fixed  to  the  right  abdomi- 
nal wall,  while  in  the  quadruped  it  is  freely  movable.  In  man  the  ascending  colon  and  descend- 
ing colon  and  the  two  flexures  are  normally  fixed  to  the  posterior  abdominal  wall  without  the 
intervention  of  mesentery,  while  in  quadrupeds  the  large  intestine  has  a  long  mesentery  and  is, 
therefore,  freely  movable.  In  man  the  great  omentum  grows  down  over  the  transverse  colon 
and  adheres  to  it.  This  does  not  occur  in  the  quadruped.  In  man  the  omental  bursa  is  usually 
obUterated  by  adhesions  of  its  layers  together.  Obhteration  does  not  take  place  in  the  quad- 
ruped. 

"In  man  the  pancreas  has  been  rotated  behind  the  peritonetma  and  fixed  to  the  abdominal 
wall.     In  quadrupeds  the  pancreas  Ues  between  the  layers  of  the  mesentery. 

"In  the  monkey,  which  is  a  quadruped  with  a  tendency  to  stand  erect,  the  pancreas  becomes 
adherent,  and  the  duodenum  is  more  firmly  fixed  than  in  the  original  quadruped. 


"The  solid  organs  of  the  upper  abdomen  which  are  fixed  in  man  and  movable  in  the  quad- 
ruped are  the  kidneys,  liver,  spleen,  and  the  pancreas. 

"The  parts  of  the  intestinal  tube  left  movable  in  man  are  the  middle  part  of  the  stomach, 
the  transverse  colon,  and  the  small  intestine  down  to  a  point  near  the  ileocecal  valve  and  the 
sigmoid  colon. 

"The  transverse  colon  is  attached  by  fusion  to  the  posterior  leaf  of  the  omentum,  which, 
in  turn,  is  attached  to  the  anterior  leaf  by  the  same  process  for  the  purpose  of  preventing  the 
middle  of  the  transverse  colon  from  sagging  and  pulling  on  the  two  flexures." 

With  this  excellent  description  of  the  anatomy  of  visceral  support  the 
pathology  of  ptosis  can  be  easily  understood. 

The  most  common  defect  in  the  supporting  attachment  is  represented  by  a 
lack  of  fusion  of  the  cecum  and  ascending  colon  to  the  parietal  peritoneum,  so 
that  this  portion  of  the  large  intestine  instead  of  being  normally  fixed  is  sus- 
pended by  a  mesentery  as  in  quadrupeds.  The  ascending  colon,  therefore,  with 
its  great  weight  of  feces  and  water,  drags  heavily  on  the  fixed  point  at  the 
hepatic  flexure,  produces  a  sharp  kink  in  the  canal,  with  consequent  retardation 
of  the  flow  of  intestinal  contents.  If  the  fixation  at  the  hepatic  flexure  is  suffi- 
ciently strong  to  resist  the  drag  of  the  colon  and  cecum,  the  cecum  gradually 
becomes  stretched  out  and  dilated,  often  reposing  deep  in  the  true  pelvis.  This 
constitutes  the  so-called  "cecum  mobile"  of  Wilms, 

There  exists  between  the  ascending  and  descending  colons  membranous 
attachments  to  the  lower  poles  of  the  kidneys.  Downward  displacement  of  the 
ascending  colon,  therefore,  exerts  a  drag  on  the  right  kidney  and  is  thought  by 
some  to  be  the  chief  cause  of  renal  prolapse. 

Displacement  of  the  descending  colon  is  much  less  common  than  on  the 
right,  because  of  the  more  powerful  attachment  at  the  splenic  flexure,  which  is 
the  last  point  to  give  way  in  extreme  cases  of  visceroptosis.  In  this  way  the 
infrequency  of  prolapse  of  the  left  kidney  is  accounted  for. 


160  GYNECOLOGY 

Ptosis  of  the  transverse  colon  may  take  place  entirely  independently  of 
the  ascending  colon,  and  is  termed  "mid-line  ptosis"  by  Coffey,  who  advances 
the  following  theory  for  its  occurrence. 

Between  the  hepatic  and  splenic  attachments  the  colon  has  no  parietal 
support.  Nature  has  attempted  to  make  up  for  this  by  fusion  of  the  inner 
surfaces  of  the  leaves  of  the  omental  bursa.  As  a  result  of  this  fusion  the 
gastrocolic  omentum  is  formed,  which  acts  to  suspend  the  colon  from  the  lower 
border  of  the  stomach.  If  the  omental  bursa  fails  to  fuse  this  support  is  want- 
ing, and  the  transverse  colon  is  susceptible  to  prolapse  as  a  result.  Ptosis  of 
the  transverse  colon  causes  sharp  kinking  of  the  two  flexures,  especially  at  its 
splenic  attachment,  with  consequent  tendency  to  severe  constipation. 

Prolapse  of  the  stomach  represents  also  a  mid-line  ptosis,  the  displacement 
occurring  between  the  firm  esophageal  attachment  on  the  left  side  and  the 
attachment  situated  at  the  second  portion  of  the  duodenum  on  the  right.  In 
this  form  of  prolapse  a  kink  is  established  at  the  point  of  duodenal  attachment, 
with  consequent  distention  of  the  duodenum,  pylorus,  and  stomach. 

According  to  Coffey,  Goldthwait,  and  others,  in  practically  all  cases  of 
enteroptosis  can  be  demonstrated  anatomic  defects  of  embryologic  fusion  and 
abnormal  mobility  of  the  intestine. 

Of  the  predisposing  causes  for  ptosis  the  most  important  are  congenital  or 
acquired  errors  in  body  form,  and  it  may  be  said  that  in  a  normally  formed 
body,  which  during  life  is  maintained  in  correct  posture,  even  if  there  be  con- 
genital defect  in  rotation  and  fusion  of  the  intestine,  ptosis  probably  does  not 
take  place. 

When  a  normal  individual  stands  in  the  proper  erect  position  the  upper 
part  of  the  abdomen  in  which  the  heay^^  organs  he  is  expanded  by  the  widen- 
ing of  the  ribs  and  the  raising  of  the  diaphragm,  while  the  lower  abdomen  is 
compressed  and  flattened  by  the  firm  contraction  of  the  abdominal  muscles. 
If  a  sagittal  section  be  made  through  the  body  in  this  position,  it  will  be  found 
that  the  outline  of  the  abdominal  cavity  is  shaped  Uke  a  pear,  with  the  large 
end  uppermost  and  inchned  backward  at  an  angle  of  51  degrees  (Coffey)  (Fig. 
23).  The  lower  curve  of  the  pear-shaped  contour  corresponds  to  an  inchned 
shelf  formed  by  the  psoas  muscle  and  a  firm  retroperitoneal  pad  of  fat  (Fig. 
23).  This  padded  shelf  helps  very  efficiently  to  sustain  the  weight  of  all  the 
heavy  organs  of  the  upper  abdomen,  excepting  the  pyloric  end  of  the  stomach 
and  the  transverse  colon,  which  He  in  front  of  the  shelf  and  which,  as  has 
been  shown,  depend  for  their  support  on  their  rather  meager  suspensory- 
ligaments. 

If,  therefore,  structural  abnormahties  of  the  body,  either  congenital  or 
acquired,  change  the  incHnation  of  the  padded  shelf,  making  it  steeper,  the 
heavy  organs  lose  their  most  important  support  and  tend  to  slide  downward, 
unless  their  attachments  to  the  parietes  are  sufficiently  firm  to  counteract  the 
influence  of  gravity  and  abdominal  pressure.     This  is  the  fundamental  prin- 


EELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM 


161 


ciple  which  underHes  the  orthopedic  treatment  of  visceroptosis,  which,  as  we 
shall  see,  plays  a  most  important  role  in  the  management  of  these  cases. 

Goldthwait,  R.  C.  Smith,  Swaim,  and  others  have  rightly  divided  enterop- 
totic  patients  into  two  types,  the  acquired  and  congenital,  with  reference  to 
changes  in  bodily  structure.  The  condition  may  be  acquired  by  faulty  posture 
in  childhood,  early  lack  of  nourishment,  habitual  constipation,  long-continued 
errors  of  posture  from  occupational  exigencies,  neglect  of  muscular  exercise, 


Fig.  23. — Section  of  a  Normal  Abdominal  Cavity  Showing  the  Pear-shaped  Contour  and  the 

Inclination  Backward  of  51  Degrees. 
Note  the  position  of  the  kidney  under  the  last  two  ribs,  and  the  supporting  shelf  of  fat  and  muscle. 


relaxation  due  to  child-bearing,  the  loss  of  bodily  fat,  etc.    The  victim  of  acquired 

ptosis  exhibits  a  general  drooping  of  the  body.     The  shoulders  drag  forward  and 

downward,  lowering  and  compressing  the  chest  wall.     The  contraction  of  the 

ribs  diminishes  the  upper  area  of  the  abdominal  cavity,  which,  as  we  have  seen, 

should  be  large  and  roomy.     Compensatory  changes  in  the  bony  framework 

alter  the  inchnation  of  the  pelvis,  with  consequent  strain  on  the  muscles  of  the 

back  and  the  articulation  of  the  sacro-ihac  joints.     The  muscles  of  the  abdomen 
11 


162 


GYNECOLOGY 


are  relaxed  and  allow  the  abdominal  contents  to  sag  downward  and  forward. 
These  structural  changes  cause  an  alteration  in  the  contour  of  the  abdominal 
cavity,  as  shown  in  Fig.  24.  The  outline,  formerly  represented  by  a  pear 
inclined  backward  at  an  angle  of  51  degrees,  assumes  a  new  shape.  The  outline 
of  the  upper  part  becomes  contracted  and  the  lower  part  enlarged,  the  whole 
assuming  more  of  an  oval  shape,  while  the  long  axis,  losing  its  inclination, 
approaches  the  perpendicular.  In  this  way  the  protecting  shelf  formed  by  the 
psoas  muscle  and  the  overlying  pad  of  fat  is  partially  obliterated,  thus  allowing 
the  downward  drag  of  gravity  on  the  heavy  organs  of  the  upper  abdomen. 

The  congenital  type  of  the  enterop- 
totic  is  much  more  common  than  the 
acquired.  In  fact,  it  is  probable  that 
even  in  most  cases  of  acquired  ptosis 
physical  errors  in  bodily  structure  of  a 
congenital  nature  can  be  traced. 

The  following  description,  quoted 
from  Swaim,  pictures  this  type: 

"As  children  they  began  Ufe  'frail';  they 
could  not  attend  school  regularly;  they  grew  up 
delicate  of  stomach,  nervous,  subject  to  attacks 
of  indigestion,  incapable  of  doing  all  the  things 
they  wished  to  do  or  that  were  expected  of 
them.  They  seldom  had  had  serious  illness; 
sooner  or  later  an  inflamed  appendix  has  been 
removed  or  the  pelvic  organs  'hitched  up'  be- 
cause of  menstrual  disorders.  At  work  they 
were  clever,  but  incapable  of  sustained  efforts 
without  the  inevitable  results.  Most  of  the 
patients  beyond  the  age  of  twenty-one  had 
had  one  or  two  nervous  breakdowns.  The 
physical  characteristics  in  such  cases  are  al- 
most typical.  Their  standing  posture  is  very 
bad;  their  shoulders  are  stooped;  scapulae 
prominent;  the  sacral  and  lumbar  curves  ex- 
aggerated; the  abdomen  prominent,  especially 
in  its  lower  half  and  with  the  chest  flat;  the 
muscles  of  the  abdomen  are  lax;  the  erector 
spinse  muscles  are  thin  and  tense,  account- 
ing largely  for  the  ache  between  the  shoulders 
and  the  tired  feeling  at  the  base  of  the  sku^' 
The  circulation  is  sluggish,  the  hands  and  feet  are  habitually  cold  and  clammy,  and  especially 
so  when  the  patient  is  under  nervous  strain.  The  blood  shows  secondary  anemia,  and  in  this 
type  the  blood-pressure  is  usually  subnormal  while  the  temperature  is  always  subnormal  in 
the  morning.  Examination  of  the  abdomen  generally  shows  it  to  be  of  the  scaphoid  variety 
with  a  very  acute  sternocostal  angle.  The  ribs  are  long  and  reach  nearly  to  the  crest  of  the 
ileum.  There  is  often  some  tenderness  with  spasm  in  the  epigastrium  or  a  httle  to  the  right  of 
it.  The  cecal  region  is  tympanitic  and  the  'corded  sigmoid'  is  usually  present.  Pressure  over 
the  epigastrium  causes  a  characteristic  feeling  of  nausea  and  distress  similar  to  the  habitual 
discomfort  experienced  by  the  patients.  Their  loins  are  thin  and  the  right  kidney  is  either  pal- 
pable or  actually  movable.     Not  seldom  the  edge  of  the  hver  can  be  felt  and  the  aorta  is  pal- 


FiG.  24. — Enteroptosis   with    Changes   in 
THE  Body  Contour. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  163 

pable  in  its  whole  length.  With  the  patient  on  his  face  there  is  a  distinct  hollowing  in  the  costo- 
vertebral angle,  showing  an  absence  of  retroperitoneal  fat.  About  10  per  cent,  of  such  cases 
have  slight  lateral  curvatures.  The  urine  usually  is  normal.  The  gastric  analysis  may  show 
normal  findings,  or  hyperacidity  or  anacidity,  and  this  varies  from  time  to  time.  The  stool 
shows,  as  a  rule,  considerable  undigested  material.  The  .x-rays  show  the  long,  tubular  'drain- 
trap'  stomach,  some  stasis  with  lack  of  peristalsis.  The  smaU  intestines  are  rarely  visible  be- 
cause of  hypermotihty,  as  demonstrated  by  the  early  filling  of  the  cecima.  In  this  type  the 
small  intestines  have  a  tendency  to  be  short.  The  radiograms  of  the  colon  show  stasis  at  the 
cecmn  or  at  the  transverse  sag.  It  seems  probable  that  a  mechanical  obstruction  of  the  bowel 
takes  place,  producing  malnutrition,  which,  in  turn,  makes  the  position  of  the  intestines  more 
potent.  Veils  and  bands  are,  of  course,  to  be  found.  Let  us  study  the  patient  more  closely. 
Normally,  abdominal  fat  covers  all  the  abdominal  organs  and  nerve  plexuses.  Where  the 
abdominal  fat  is  lacking  they  are  exposed.  It  is  generally  believed  that  fat  supports  the  kid- 
neys, plus  the  more  obvious  supports. 

"In  these  patients  there  is  almost  always  a  lack  of  fat  tissue.  The  drag  downward  of  the 
stomach  and  intestines  must  come  on  their  attachments,  especially  the  mesentery,  which 
carries  aU  the  nerves  and  the  blood-vessels  of  the  small  intestines  and  transverse  colon." 

In  a  very  considerable  percentage  of  cases  of  congenital  enteroptosis  there 
exists  some  pelvic  abnormality  with  corresponding  symptoms,  and  it  is  for  this 
reason  that  the  gynecologist  shares  an  equal  interest  in  the  subject  with  the 
internist,  general  surgeon,  and  orthopedist. 

As  was  stated  above,  there  is  no  very  definite  causal  relationship  between 
enteroptosis  and  pelvic  disease,  excepting  in  cases  where  pelvic  adhesions  may 
cause  a  forcible  dragging  down  or  fixation  of  the  intestines.  The  pelvic  abnor- 
mality so  frequently  accompanying  enteroptosis  is  to  be  regarded  rather  as  an 
associated  condition,  and  usually  represents  some  form  of  genital  hypoplasia. 
It  is,  of  course,  possible  that  early  ill  nourishment  of  the  congenital  ptotic 
may  interfere  with  the  full  development  at  puberty  of  the  genital  organs,  but 
this  is  probably  not  an  important  element,  in  view  of  the  fact  that  a  very  large 
number  of  patients  are  seen  with  genital  hypoplasia  who  are  otherwise  com- 
pletely developed  and  without  the  slightest  tendency  to  enteroptosis.  In 
individuals  who  manifest  a  lack  of  development  elsewhere  it  is  to  be  expected 
that  the  generative  system  should  share  in  the  general  physical  deficiency,  at 
least  in  a  considerable  percentage  of  cases,  and  this  is  true  of  the  ptotic  patient. 
The  independence  of  development  that  the  genitals  often  exhibit  with  reference 
to  the  rest  of  the  body  is  not  infrequently  shown  in  the  congenital  enteroptotic 
by  an  entirely  normal  pelvic  apparatus. 

The  abnormalities  of  the  pelvis  most  often  associated  with  enteroptosis  are 
malpositions,  usually  either  anteflexion  with  retrocession  or  retroflexion.  Occa- 
sionally one  encounters  a  procidentia  in  a  nuUiparous  woman.  Deficiency  of 
ovarian  function  with  amenorrhea  or  ohgomenorrhea  is  frequent.  Dysmenor- 
rhea and  sterility  are  extremely  common. 

The  symptomatology  of  enteroptosis  is  a  subject  so  extensive  that  it  can  be 
touched  on  only  superficially  here.  The  symptoms  are  due  to  the  retardation 
in  the  bowel  of  the  fecal  contents,  a  condition  aptly  termed  by  Lane  "intestinal 
stasis,"  and  are  evoked  by  the  absorption  into  the  circulation  of  toxic  products 


164  GYNECOLOGY 

from  the  stagnating  and  decomposing  material.  The  typical  sjmiptoms  consist 
of  frequent  nausea  and  vomiting,  often  severe  and  sometimes  accompanied  with 
blood,  loss  of  appetite,  diminution  in  body  weight,  sometimes  rapid,  circula-  ■ 
tory  disturbances,  such  as  coldness  of  hands  and  feet,  constipation  with  much 
gas  formation  of  the  bowels  and  discomforting  distention,  mental  apathy,  and 
a  great  variety  of  muscular  and  joint  pains.  Many  of  the  patients  exhibit  char- 
acteristic skin  changes,  especially  acne  and  sallowness  of  the  complexion.  Ner- 
vous symptoms  of  all  kinds  and  severity,  amounting  sometimes  to  mental 
derangement,  are  practically  always  present.  Swaim  has  called  attention  to 
the  possibiUty  that  much  of  the  symptomatology  may  be  referable  to  pressure 
and  stimulation  of  nerves  of  the  sympathetic  ganglia,  with  consequent  influence 
on  the  organs  of  internal  secretion. 

If  pelvic  abnormalities  are  present,  and  sometimes  even  when  they  are 
not  demonstrable,  there  may  be  severe  disturbances  of  menstruation,  usually 
dysmenorrhea,  and  various  forms  of  genital  psychoneuroses. 

As  a  result  of  the  studies  of  Metchnikoff  and  Lane,  many  diseases  are  thought 
to  be  the  direct  resultant  from  the  auto-intoxication  of  intestinal  stasis,  such  as 
arteriosclerosis,  nephritis,  diabetes  melhtus,  rheumatism,  various  arthritides, 
ulcer  of  the  stomach,  cholehthiasis,  cystic,  and  malignant  degeneration  of  the 
breast,  etc.  Undoubtedly,  the  lov\^ering  of  general  resistance  caused  by  enterop- 
tosis  makes  the  individual  more  susceptible  to  these  diseases,  even  if  the  rela- 
tionship is  not  more  direct.  Metchnikoff  has  succeeded  in  producing  cal- 
careous deposits  in  the  arterial  walls  of  animals  in  whom  an  artificial  intestinal 
stasis  has  been  created. 

The  diagnosis  of  enteroptosis  and  stasis,  though  frequently  obvious,  is  in 
all  cases  ultimately  made  by  a;-ray  pictures  of  the  intestine,  the  details  and 
significance  of  which  should  be  interpreted  only  by  an  expert  rontgenologist. 

The  treatment  of  enteroptosis  calls  for  the  cooperation  of  more  specialties 
than  almost  any  other  disease,  and  may  require  medical,  orthopedic,  surgical, 
gynecologic,  and  neurologic  measures. 

Medical  treatment  is  necessary  in  all  cases,  and  consists  primarily  in  pre- 
scribing a  simple  digestible  diet  and  a  proper  course  of  hygiene.  At  first  the 
lubrication  of  the  intestine  must  be  gained,  and  for  this  the  better  preparations 
of  liquid  paraffin  (Russian  oil)  are  at  present  in  the  greatest  favor.  Hydro- 
therapy when  available  is  unquestionably  of  much  benefit. 

Orthopedic  treatment  is  in  all  cases  of  the  greatest  importance,  even  when 
drastic  surgical  measures  are  undertaken.  It  consists  in  the  appHcation  of 
braces  and  supports  which  correct  the  posture  and  support  the  prolapsed 
viscera.  In  addition,  the  patient  is  taught  to  assume  various  positions  which 
reheve  the  drag  of  the  viscera  and  to  perform  numerous  exercises  to  strengthen 
the  weakened  muscles  of  the  trunk.  The  problem  of  the  orthopedic  treatment 
has  been  worked  out  pre-eminently  by  Goldthwait,  to  whose  writings  the  reader 
is  especially  referred.     Inasmuch  as  the  body  form  is  faulty  in    all  cases   of 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM 


165 


enteroptosis,  orthopedic  treatment  must  supplement  all  other  measures.  This 
is  not  sufficiently  recognized  in  the  cases  which  are  treated  surgically.  Gold- 
thwait  has  emphasized  this  point  in  the  following  (shghtly  modified)  quotation: 

"Special  attention  may  be  given  to  a  particular  organ,  but  the  importance  of  the  influence 
of  the  other  organs  or  other  structures  upon  the  special  organ  must  not  be  lost  sight  of.  Opera- 
tions may  be  performed,  but  before  it  is  attempted  to  sew  a  stomach  in  what  is  supposed  to  be 
its  normal  position,  it  must  be  seen  that  the  body  is  so  remodeled  that  the  proper  amount  of 
subdiaphragmatic  space  exists  for  the  organs.  A  hole  must  be  prepared  before  a  peg  can  be  put 
into  it.  To  suture  a  stomach  or  Uver  to  the  upper  abdominal  region,  when  the  ribs  and  dia- 
phragm are  so  low  that  when  the  body  is  used  they  continually  crowd  the  attached  organs  do\\Ti- 
ward,  must  frequently  result  in  gi-eater  discomfort  than  existed  before.  A  movable  organ  under 
such  conditions  is  better  than  a  fixed  one,  because  it  may  have  periods  of  ease  or  acquire  new 
positions  in  which  reasonable  function  is  possible.  In  the  fixed  position  this  mechanical  inter- 
ference may  be  constant.  When  such  operations  are  required,  if  the  body  is  considered  with 
reference  to  all  its  parts  and  the  mechanistic  significance  of  the  relationship  of  the  many  organs 
each  to  the  other  is  kept  in  constant  memory,  care  must  be  taken  to  see  that  the  body  is  pre- 
pared by  a  period  of  remodeling,  or  special  exercises  are  given,  or  postures  assumed,  so  that  the 
organ  when  put  in  place  can  have  the  best  chance  to  do  its  work." 

The  surgical  treatment  of  enteroptosis  is  also  too  broad  a  subject  to  be 
treated  here  more  than  superficially,  and  is  at  the  the  same  time  in  such  an 
experimental  stage  that  definite  conclusions  are  as  j-et  unjustifiable.  In  speak- 
ing of  the  surgery  of  enteroptosis  it  is  to  be  noted  that  we  do  not  include  opera- 
tions for  the  frequently  associated  membranous  adhesions,  a  subject  which  is 
dealt  with  later  (see  page  176). 

Some  of  the  operations  that  have  been  emploj'-ed  with  greater  or  less  suc- 
cess are  as  follows.  Rovsing,  a  pioneer  in  this  branch  of  surgery,  has  sutured 
the  stomach  wall  directly  to  the  peritoneum  of  the  anterior  abdomen,  and  has 
from  time  to  time  reported  astonishingly  good  results.  His  method,  however, 
has  not  been  general^  adopted. 

Beyea  shortened  the  gastrohepatic  ligament,  but  this  method,  though  sounder 
in  surgical  principle  than  that  of  Rovsing,  proved  inadequate  on  account  of  the 
natural  weakness  of  the  hgament.  Lane,  to  whom  belongs  the  chief  credit  of 
demonstrating  to  the  profession  the  possibihties  of  surgery  in  the  treatment  of 
ptosis,  applied  heroic  measures  by  either  removing  the  colon  entire  or  short- 
circuiting  it  by  cutting  off  the  ileum  and  planting  it  in  the  lower  bowel.  These 
radical  operations  have  been  widely  tried,  but  with  rather  disappointing 
results. 

Wilms,  recognizing  the  importance  of  the  stretched-out  movable  cecum 
in  the  condition  of  stasis,  fixed  the  cecum  to  the  lateral  parietal  wall  with  con- 
siderable success. 

Coffey,  appreciating  the  principle  of  suspension  without  fixation,  devised 
an  operation  which  has  proved  very  efficient.  The  steps  of  the  operation  are  as 
follows:  First,  shortening  by  plication  the  falciform  peritoneum,  thus  sustaining 
the  liver;  second,  shortening  the  gastrohepatic  omentum  by  plication  (Beyea's 
method),  thus  giving  a  greater  support  to  the  stomach;  third,  suturmg  the 


166  GYNECOLOGY 

greater  omentum  along  a  line  just  below  the  transverse  colon  to  the  parietal 
peritoneum,  thus  affording  a  strong  support  both  for  the  colon  and  indirectly 
the  stomach.  In  addition  to  the  operations  of  suspending  the  viscera,  an 
attempt  is  made  to  restore  the  contour  of  the  abdominal  cavity  by  enlarging  the 
space  of  the  upper  abdomen  and  compressing  that  of  the  lower  abdomen.  This 
is  accomphshed  by  sphtting  the  anterior  sheaths  of  each  rectus  muscle  and  by 
leaving  unsutured  the  wound  of  the  aponeurosis  made  by  the  original  incision. 
The  pendulous  lower  abdomen  is  strengthened  by  a  special  plastic  operation  of 
overlapping  the  aponeurosis.  Coffey's  operation,  on  account  of  its  simplicity 
and  logicalness,  has  been  very  extensively  employed,  with  varying  results. 

In  giving  a  general  estimate  of  the  surgery  of  enteroptosis  in  the  hght  of 
present  experience  it  may  be  said  that  notwithstanding  the  numerous  failures 
that  have  been  recorded  against  it,  the  brilliant  results  of  Lane,  Coffey,  and 
others  have  demonstrated  that  certain  cases  of  enteroptosis  are  surgical  and  that 
failures  are  often  due  to  lack  of  judgment  in  selection  of  cases,  inadequate 
experience  in  performing  the  operations,  and,  above  all,  to  inappreciation  of 
the  orthopedic  requirements  of  practically  all  cases. 

As  to  the  various  operations  that  have  been  employed  it  may  be  said  that 
the  complete  resection  of  the  colon  is,  in  our  present  state  of  knowledge  and 
experience,  too  radical  a  procedure,  excepting  in  extreme  cases,  though  in  the 
light  of  the  continued  verification  of  Metchnikoff's  theories  one  cannot  help 
believing  that  at  some  future  period  the  operation  may  become  one  of  immense 
benefit  to  the  human  race.  Short-circuiting  of  the  colon  is  also  looked  on  with 
disfavor  by  many  surgeons,  whp  have  tried  it  enthusiastically,  only  to  be  disap- 
pointed in  its  results.  In  certain  cases,  however,  there  is  no  doubt  of  its  value. 
The  conservative  operation  of  Coffey  is  also  at  the  time  of  writing  looked  upon 
unfavorably  by  numerous  surgeons,  who  have  not  found  in  it  the  universal 
panacea  that  they  had  anticipated.  We  have  personally  found  it  extremely 
useful,  and  ascribed  the  failures  that  we  have  met  with  to  inexperience  in  the 
technic  and  to  a  neglect  of  the  orthopedic  requirements. 

The  gynecologic  treatment  of  enteroptotic  patients  is  the  same  as  that  of 
pelvic  disease  under  other  conditions.  It  must,  however,  be  borne  in  mind  by 
the  surgeon  and  explained  to  the  patient  that  surgical  treatment  of  the  pelvic 
organs  is  directed  toward  the  local  symptoms  only,  and  that  relief  of  them  does 
not  involve  a  disappearance  of  the  train  of  symptoms  caused  by  stasis  of  the 
intestines.  For  this  reason  it  is  of  the  greatest  importance  that  the  gynecol- 
ogist should  be  familiar  with  the  pathology  and  clinical  picture  of  enteroptosis. 
Fortunately  the  idea  is  passing — though  it  has  not  yet  entirely  passed — that 
all  kinds  of  digestive  disturbances,  muscular  pains,  and  nervous  derangements 
may  be  ''reflexes"  resulting  from  a  misplaced  uterus  or  cystic  ovary. 

If  the  pelvic  organs  are  giving  the  enteroptotic  definite  symptoms  for  which 
a  pelvic  operation  offers  a  reasonable  hope  of  relief,  the  operation  is  indicated. 
If  the  ptotic  condition  is  also  one  for  surgery,  the  two  operations  may  be  done 


KELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  167 

at  the  same  time,  with  proper  regard  also  for  the  necessity  of  orthopedic  remodel- 
ing of  the  faulty  body  structure. 

Of  much  importance  in  the  performance  of  the  pelvic  operation  is  a  con- 
sideration of  the  abdominal  wall,  which  in  most  cases  is  in  a  state  of  relaxation. 
The  operation  recommended  by  the  author  (see  page  771)  may  be  used  with 
much  advantage  to  strengthen  the  wall  and  compress  the  lower  part  of  the  ab- 
dominal cavity.  It  is  of  especial  value  in  cases  of  acquired  ptosis  where  there 
is  usually  a  diastasis  of  the  recti  muscles. 

Neurologic  treatment  of  the  enteroptotic  is  less  prominent  than  it  was  be- 
fore the  chnical  significance  of  the  condition  was  generally  recognized,  and 
when  these  patients  were  regarded  as  hopeless  neurasthenics. 

In  some  cases,  however,  modern  neurologic  treatment  is  of  prime  importance 
in  securing  a  complete  recovery.  These  are  the  cases  in  whom  the  neurotic 
habits  of  introspection  and  overvaluation  of  symptoms  have  become  so  estab- 
lished that  they  do  not  entirely  disappear  after  rehef  of  the  physical  disability. 
These  habit-neuroses  are  best  treated  by  the  methods  of  reasoning  and  sugges- 
tion with  which  the  expert  neurologists  of  today  are  acquiring  such  brilliant 
results. 

MOVABLE  KIDNEY 

The  term  "movable  kidney"  is  a  general  one,  relating  to  conditions  of  abnormal 
mobility  of  the  kidney.  Nephroptosis  means  falling  or  prolapse  of  the  kidney, 
.  and  is  practically  synonymous  with  movable  kidney.  Floating  kidney,  when 
properly  used,  relates  to  the  more  extreme  cases  of  movable  kidneys  such  as 
when  the  organ  becomes  completely  invested  by  a  covering  of  peritoneum  and 
hangs  loose  in  the  abdominal  cavity,  or  when  it  descends  to  the  pelvis,  or  when 
it  lies  close  to  the  anterior  abdominal  wall.  Under  these  conditions  the  stretched 
out  supporting  tissues  constitute  a  sort-  of  mesentery  from  which  the  kidney 
swings. 

Movable  kidney  is  so  common  in  women  that  it  is  included  in  the  category 
of  gynecologic  diseases.  Formerly  supposed  to  be  rare,  it  is  now  under  im- 
proved methods  of  diagnosis  estimated  to  occur  in  one  out  of  every  five  women, 
in  contrast  to  men,  in  whom  the  occurrence  is  only  2  per  cent.  In  the  vast 
majority  of  cases  only  the  right  kidney  is  affected.  In  a  comparatively  small 
percentage  both  kidneys  are  involved,  while  prolapse  of  the  left  kidney  .alone 
is  extremely  rare. 

Kelly's  figures  show  f?iat  symptoms  of  movable  kidney  appear  most  fre- 
quently between  the  ages  of  twenty  and  thirty,  and  that  the  condition  is  very 
rare  in  the  young.  Kelly  thinks  that  the  development  of  symptoms  so  fre- 
quently seen  during  the  third  decade  may  possibly  be  due  to  the  fact  that 
this  is  usually  the  most  active  period  of  a  woman's  life  as  regards  bodily  effort 
and  child-bearing. 

The  etiology  of  movable  kidney  has  been  a  subject  of  much  theory  and 


168  GYNECOLOGY 

speculation.  In  by  far  the  great  majority  of  cases  the  condition  is  acquired,  a 
congenital  origin  having  been  established  in  only  a  few  cases.  Of  the  pre- 
disposing causes  some,  which,  in  the  earlier  studies  of  the  disease  were  regarded 
as  important,  may  be  excluded  as  having  little  or  at  least  only  secondary  in- 
fluence. Of  these  may  be  mentioned  tight  lacing.  The  corsets  in  vogue  at  one 
period,  which  constricted  the  upper  portion  of  the  abdomen  and  a  part  of  the 
chest  wall,  may  have  acted  in  conjunction  with  more  fundamental  influences 
in  forcing  the  kidney  downward.  Pregnancy  and  labor,  once  thought  to  be  a 
frequent  primary  factor,  probably  act  only  secondarily  in  relaxing  the  lower  ab- 
dominal wall,  thus  favoring  a  tendency  to  visceroptosis  in  which  the  kidney 
may  have  a  share.  The  frequency  with  which  movable  kidney  is  found  in  the 
nuUiparous  and  the  old-maid  type  is  evidence  that  pregnancy  is  not  to  be 
regarded  as  of  primary  importance. 

Traumatism  in  the  form  of  sudden  falls  and  jars,  once  regarded  as  a  fre- 
quent cause  of  acute  prolapse  of  the  kidney,  can  probably  be  excluded.  As  in 
cases  of  retroversion  and  prolapse  of  the  uterus,  or  other  forms  of  relaxed  tissues, 
the  pathologic  condition  is  the  result  of  gradual  stretching,  either  from  con- 
stant strain  or  often-repeated  traumatism.  Congestion  of  the  kidney,  asso- 
ciated with  menstruation  or  pregnancy  or  malposition  of  the  uterus,  is  of  very 
minor  significance  as  an  etiologic  factor  in  nephroptosis,  though  it  may  often 
act  to  exaggerate  the  symptoms  if  such  a  condition  already  exists. 

The  fundamental  etiology  of  movable  kidney  in  the  light  of  present  knowl- 
edge is  probably  contained  in  the  following  conditions:  (1)  Physiologic  defi- 
ciency of  supporting  structures;  (2)  errors  in  bodily  structure;  (3)  drag  on  the 
kidney  of  the  cecum  and  ascending  colon;  (4)  loss  of  supporting  fat. 

In  most  cases  of  relaxed  organs  it  is  self-evident  that  there  exists  in  the 
individual  some  inborn  deficiency  in  the  supporting  tissue  structure,  rendering 
it  unable  to  resist  adequately  the  ordinary  exigencies  of  physical  life.  This 
tissue  deficiency  may  be  general,  as  in  cases  of  general  visceroptosis,  or  localized, 
as  in  the  case  of  a  movable  kidney  or  a  retroverted  uterus  that  exists  in  an 
individual  otherwise  perfectly  sound. 

Of  chief  importance  in  the  etiology  of  movable  kidney  is  the  body  form,  to 
which  it  bears  the  same  relationship  as  does  enteroptosis.  As  has  been  shown 
in  the  discussion  of  enteroptosis,  the  heavy  organs  of  the  abdomen,  including 
the  kidneys,  are  contained  in  the  upper  portion  of  the  abdominal  cavity,  the 
contour  of  which  in  the  normal  individual  is  shaped  like  a  pear,  inclining  back- 
ward at  an  angle  of  51  degrees.  This  inclination  provides  a  sort  of  shelf  which, 
with  the  aid  of  abdominal  pressure  and  the  padding  of  postperitoneal  fat,  sup- 
ports all  the  heavy  organs  excepting  the  transverse  colon  and  the  pyloric  half 
of  the  stomach.  On  this  padded  shelf  the  kidney  is  .especially  dependent  for 
its  support.  The  inclination  of  the  shelf,  and  consequently  its  supporting 
power,  is  altered  by  changes  in  the  body  form  caused  by  relaxation  and  droop- 
ing.   The  upper  roomy  portion  becomes  constricted  by  collapse  of  the  chest  wall 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  169 

and  the  contents  are  forced  downward.  The  lower  abdomen  becomes  larger, 
the  long  axis  of  the  cavity  more  vertical,  and  the  pear-shaped  outline  of  the 
abdominal  cavity  more  cylindric.  Hence  the  frequency  with  which  nephrop- 
tosis is  found  in  individuals  who,  either  by  inheritance  or  by  improper  posture, 
or  by  occupational  requirements  or  other  cause,  are  bodily  malformed. 

There  is .  an  undoubted  influence  between  movable  kidney  and  movable 
cecum.  During  the  process  of  rotation  of  the  intestine  during  embryonal  life 
and  its  adaptation  to  the  erect  posture  of  man,  the  ascending  colon,  as  has  been 
stated  on  page  159,  becomes  fused  with  the  posterior  parietal  wall  and  the 
anterior  aspect  of  the  kidney.  It  has  been  shown  by  anatomists  that  in  20 
per  cent,  of  subjects  coming  to  the  autopsy  talkie  there  has  been  an  incom- 
plete fusion  of  the  lower  part  of  the  ascending  colon,  so  that  instead  of  being 
supported  by  an  attachment  to  the  parietal  wall  it  swings  free  on  a  mesentery, 
constituting  the  so-called  cecum  mobile  of  Wilms.  The  weight  of  the  cecum, 
therefore,  bears  heavily  on  its  attachment  to  the  kidney,  which,  if  its  natural 
supports  are  congenitally  inadequate,  or  if  the  angle  of  the  padded  shelf  is  less- 
ened b}^  incorrect  body  form,  is  dragged  from  its  bed.  Longyear,  who  has  writ- 
ten a  book  on  the  subject,  believes  this  to  be  the  sole  cause  of  movable  kidney. 

The  presence  of  fat  in  the  shelf  on  which  the  kidney  rests  is  of  considerable 
importance.  The  shelf,  as  has  been  seen,  is  composed  of  the  psoas  muscle  and  a 
pad  of  fat.  If  this  pad  of  fat  is  lost  by  absorption,  the  shelf  loses  its  supporting 
angle.  Just  how  far  this  acts  as  a  primary  cause  is  problematic.  Kelly  has  shown 
in.  his  statistics  that  the  rapid  absorption  of  bodily  fat  is  by  no  means  con- 
stantly followed  by  nephroptosis,  while  on  the  other  hand  a  very  considerable 
number  of  his  cases  were  either  fat  or  moderately  well  nourished.  It  is  not 
unlikely  that  the  absence  of  the  supporting  fat  pad,  often  noted  in  connection 
with  movable  kidney,  is  due  to  pressure  which,  as  is  well  known,  is  a  potent 
factor  in  causing  the  rapid  disappearance  of  fat. 

S5rmptoms. — In  the  great  majority  of  cases  movable  kidney  causes  no 
symptoms  whatever,  and,  considering  the  very  great  frequency  of  the  condition, 
only  exceptionally  requires  treatment.  As  is  the  case  with  the  relaxation  of 
other  organs,  the  severity  of  the  symptomiS  does  not  correspond  to  the  degree  of 
prolapse,  some  of  the  most  troublesome  symptoms  occurring  with  only  slight 
descent  of  the  kidney. 

Of  the  symptoms  which  make  treatment  of  nephroptosis  necessary  is  local- 
ized pain  in  the  kidney  region.  This  may  be  of  a  constant  dull  dragging  charac- 
ter, or  it  may  consist  of  sharp  attacks  resembling  renal  colic,  sometimes  at- 
tended with  vomiting  and  prostration. 

The  dull  dragging  pain  is  felt  in  the  back,  the  loin,  and  in  the  region  in  front 
of  the  kidney.  It  is  sometimes  associated  with  a  sensation  of  something  being 
loose  in  the  right  abdomen.  It  is  frequently  exaggerated  by  menstruation,  and 
is  always  worse  during  pregnancy.  The  pain  can  be  reproduced  in  character 
by  filling  and  slightly  distending  the  kidney  pelvis  with  fluid.     According  to 


170  GYNECOLOGY 

Kelly,  there  is  very  little  tendency  of  the  pain  to  radiate  downward,  as  in  the 
case  of  pain  from  stone.  Sharp  attacks  of  pain  are  less  common  than  the  dull 
dragging  variety.  They  represent  sometimes  the  result  of  twisting  or  kinking 
the  ureter  with  temporary  hydronephrosis;  sometimes  a  twisting  of  the  renal 
pedicle  without  urinary  obstruction.  The  attacks  of  pain  when  due  to  urinary 
obstruction  may  be  followed  by  passing  a  large  quantity  of  urine. 

In  many  cases  of  nephroptosis  there  are  marked  gastro-intestinal  disturb- 
ances. These  take  the  form  of  gastric  indigestion,  severe  constipation,  mucous 
colitis,  etc.  These  symptoms  must  not  be  regarded  as  ''reflexes"  resulting 
from  descent  of  the  kidney.  They  are  probably,  as  a  rule,  manifestations  of 
gastro-intestinal  stasis  from  associated  enteroptosis.  The  fact  that  such  symp- 
toms are  sometimes  cured  by  fixation  of  the  kidney  may  be  explained  by  the 
mechanical  relief  which  the  operation  may  afford  to  the  drag  on  various  parts  of 
the  intestinal  tract  which  the  prolapse  of  the  kidney  accentuated. 

Patients  with  nephroptosis  are  frequently  nervous,  but  the  nervous  mani- 
festations are  in  no  sense  reflexes  in  the  common  acceptance  of  the  term.  They 
bear  a  causal  relation  to  the  kidney  only  when  the  nephroptosis  is  causing  symp- 
toms which  by  constant  repetition  irritate  the  nervous  system.  The  effect 
on  the  nerves,  therefore,  follows  the  law  emphatically  laid  down  in  the  discus- 
sion of  genital  neuroses  in  the  section  devoted  to  Neurology. 

Rare  symptoms  of  movable  kidney  are  jaundice  and  attacks  of  pain  in  the 
gall-bladder  region,  clue  probably  to  an  obstruction  of  the  gall-bladder  from  the 
drag  which  a  movable  kidney  exerts  on  the  duodenal  attachment  of  the  intes- 
tine to  the  posterior  parietal  wall.  Besides  these,  other  unusual  symptoms  are 
headaches,  albuminuria,  hematuria,  irritation  of  the  bladder,  intercostal  neural- 
gia, palpitation  of  the  heart,  edema  of  the  legs. 

Edebohls  has  demonstrated  the  frequency  with  which  movable  right  kidney 
and  appendicitis  are  associated.  He  ascribes  the  inflammation  of  the  appendix 
to  the  effect  of  congestion  of  the  appendical  veins  caused  by  the  pressure  of  the 
kidney  on  the  mesenteric  veins  against  the  head  of  the  pancreas. 

The  diagnosis  of  movable  kidney  is  a  comparatively  simple  matter,  but  the 
decision  as  to  whether  in  a  given  case  the  symptoms  are  clue  to  the  malposition 
of  the  kidney  or  to  disturbance  of  some  other  organ  may  be  very  difficult. 
Diseases  of  the  ureter,  appendix,  cecum,  ascending  colon,  and  the  gall-bladder 
region  must  all  be  carefully  excluded. 

The  anatomic  position  of  the  kidney  can  usually  be  determined  by  palpa- 
tion. The  patient  is  fiat  upon  her  back  with  the  knees  drawn  up.  The  left 
hand  is  placed  flat  under  the  left  flank,  the  ends  of  the  fingers  reaching  the 
costovertebral  angle  of  the  last  rib.  This  hand  is  held  firmly,  while  the  fingers 
of  the  right  hand  are  pressed  in  front,  just  below  the  costal  margin.  The 
patient  is  requested  to  draw  in  a  deep  breath  and  then  breathe  out  quickly. 
The  movable  kidney  can  be  felt  as  a  smooth  body  slipping  between  the  fingers. 
A  normally  placed  kidney  cannot  be  felt  except  in  very  thin  individuals. 


RELATIONSHIP    OF    GYNECOLOGY    TO    THE    GENERAL    ORGANISM  171 

The  amount  of  descent  is  divided  by  Glenard  into  three  degrees.  By  his 
classification  the  kidney  is  in  the  first  degree  of  prolapse  when  the  lower  pole 
can  just  be  felt  on  deep  inspiration;  it  is  in  the  second  degree  when  the  body  of 
the  kidney  can  be  caught  and  held  near  its  center  and  prevented  from  receding 
when  the  patient  breathes  out;  it  is  in  the  third  degree  when  on  deep  inspira- 
tion the  entire  kidney  can  be  grasped  and  prevented  from  receding  on  expira- 
tion by  holding  the  anterior  and  posterior  walls  together  above  the  prolapsed 
organ. 

In  doubtful  cases  the  pelvis  of  the  kidney  may  be  injected  through  a  cysto- 
scope  and  ureteral  catheter.  By  this  means  the  capacity  of  the  kidney  pelvis 
is  tested  and  the  presence  or  absence  of  hydronephrosis  noted.  The  average 
capacity  of  the  pelvis  is  5  to  10  or  12  cm.  Kelly  estimates  that  in  1  out  of  every 
7  cases  of  nephroptosis  that  give  symptoms  there  is  a  beginning  hydronephrosis. 

The  plan  of  injecting  the  pelvis  has  been  shown  by  Kelly  to  be  of  advantage 
in  determining  the  diagnosis,  in  that  when  the  pelvis  is  filled  to  distention  the 
pain,  which  the  patient  has  been  suffering  as  a  result  of  prolapse  of  the  kidney, 
is  exactly  reproduced. 

If  the  pelves  of  both  kidneys  are  filled  with  a  metal  salt,  like  collargol,  an 
:c-ray  picture  can  be  taken  with  the  patient  standing,  from  which  very  important 
information  can  be  gained  as  to  the  comparative  size  and  position  of  the  kidney. 
This  method  of  examining  the  pelvis  of  the  kidney  is  termed  "pyelography,"  and 
is  very  extensively  used  in  diagnosis.  The  method,  however,  is  not  without 
danger.  Buerger  has  recently  reported  cases  in  which  both  collargol  and 
argyrol,  used  for  the  purposes  of  pyelography,  penetrated  into  the  renal  paren- 
chyma as  far  as  the  surface  of  the  kidney  and  produced  areas  of  necrosis  and 
suppuration. 

Treatment  of  movable  kidney  is  to  be  employed  only  when  the  displace- 
ment is  causing  definite  symptoms.  When  there  are  no  symptoms  present  it  is 
important  to  avoid  informing  the  patient  that  she  has  a  movable  kidney,  for 
knowledge  of  this  kind  in  nervous  wom,en  may  create  psychoneuroses  and  fixed 
ideas  that  become  seriously  troublesome. 

When  a  movable  kidney  is  giving  symptoms  it  may  be  treated  by  either 
orthopedic  or  surgical  measures,  or  by  both. 

Orthopedic  measures  consist  primarily  in  correcting  and  remodeling  the 
body  when  errors  in  structure  are  present.  This  is  done  by  braces,  postural  and 
muscular  exercises,  as  described  in  the  section  on  Enteroptosis.  In  addition  to 
this,  the  application  of  a  properly  fitting  abdominal  support,  sometimes  supplied 
with  a  pad,  is  most  efficient  in  relieving  and  often  entirely  curing  the  sjonptoms 
of  movable  kidney.  Whether  in  such  cases  an  anatomic  cure  of  the  position  of 
the  kidney  is  completely  secured  is  doubtful,  but  this  is  not  necessary  if  the 
patient  is  relieved  of  her  pain  and  discomfort. 

Operative  measures  seek  to  attach  the  loose  kiclnej'  to  the  muscles  which 
lie  behind  it,  so  that  it  is  prevented  from  descending.     The  operation  when 


172  GYNECOLOGY 

properly  performed  and  applied  to  the  right  ease  is  usually  successful.  Many 
operations  have  been  devised  for  the  condition,  one  of  which  is  described  in 
detail  on  page  800. 

INTESTINAL  BANDS 

The  subject  of  intra-abdominal  bands  is  closely  allied  to  that  of  enterop- 
tosis,  in  that  the  two  conditions  are  quite  constantly  associated.  Xevertheless, 
they  may  appear  independent  1}^  of  each  other,  and  for  that  reason  it  seems  best 
to  treat  the  subjects  separately. 

Science  is  at  the  present  time  in  a  quandary  as  to  the  true  etiology  of  these 
membranous  bands,  but  the  discovery  of  their  existence  and  recognition  of  their 
clinical  significance  constitute  an  important  step  in  medical  progress.  Numer- 
ous types  of  these  structures  have  been  described,  and  to  them  have  been  given 
picturesque  names,  a  familiarity  with  which  is  necessary  for  the  understanding 
of  the  literature  on  the  subject.  Some  of  the  descriptions  relate  to  bands  that 
are  found  in  the  fetus,  while  others  represent  structures  encountered  during 
adult  life. 

(1)  The  Bloodless  Fold  of  Treves. — This  is  a  prenatal  fold  of  peritoneum 
covering  the  head  of  the  cecum  and  appendix,  and,  according  to  Eastman, 
found  in  more  than  20  per  cent,  of  fetuses.  Eastman's  description  of  this  fold 
as  he  finds  it  is  as  follows: 

"It  passes  from  the  lateral  posterior  peritoneum  to  the  terminal  part  of  the  ileum  and  the 
caput  coli,  fusing  with  the  peritoneum  covering  the  intestine.  It  is  always  more  or  less  fan 
shaped,  the  broad  attachment  being  to  the  mural  peritoneum.  The  intestinal  end  is  always  the 
more  narrow.  It  forms  a  pocket  in  which  the  vermiform  appendix  and  more  or  less  of  the  caput 
coH  and  cecum  are  ensconced." 

Every  surgeon  will  recognize  having  met  with  apparently  non-inflammatory 
folds  similar  to  this  during  the  removal  of  the  appendix,  and  having  called  the 
condition  one  of  "retroperitoneal  appendix." 

(2)  The  Parietocolic  Fold  of  Jonnesco  and  Juvara. — This  is  another  mem- 
branous fold  discovered  in  the  study  of  fetuses.  In  the  majority  of  the  cases 
the  fetal  fold  arises  from  the  peritoneum  at  the  left  or  inner  side  of  the  ascending 
colon,  passing  over  the  anterior  aspect  of  the  ascending  colon  in  an  upward  slant- 
ing direction.  It  is  attached  to  the  parietal  peritoneum  at  the  right  of  the 
ascending  colon.  It  may  adhere  to  the  anterior  and  lateral  aspects  of  the 
colon  (Bainbridge) . 

The  similarity  between  this  fetal  structure  and  Jackson's  membrane  is  to 
be  noted. 

(3)  Jackson's  membrane  is  a  peritoneal  fold  frequently  observed  during 
abdominal  operations  and  described  by  Jackson,  who  considered  it  the  result 
of  an  inflammatory  process.     His  description  of  the  structure  is  as  follows: 

"From  a  point  iust  at  the  hepatic  flexure  to  three  inches  above  the  caput  coU  there  spreads 
from  the  parietal  margin  over  the  external  lateral  margin  to  the  internal  longitudinal  muscle 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      173 

band  a  thin  vascular  veil  in  which  long  straight  unbranching  blood-vessels  course,  most  of 
which  are  parallel  with  each  other,  and  take  a  slightly  spiral  direction  over  the  colon  from  the 
upper  peritoneal  attachment  to  the  inner  lower  portion  of  the  gut,  ending  just  above  the  caput. 
The  appendix  is  not  imphcated  in  any  way.  Coursing  with  the  blood-vessels  are  numbers  of 
shining  narrow  bands  of  connective  tissue,  which  gradually  broaden  as  they  go  and  end  in  a 
shght  fan-shaped  attachment  at  various  points  on  the  anterior  and  inner  surfaces  of  the  colon. 
At  these  points  of  attachment  the  gut  is  held  in  rigid  pUcation.  At  the  beginning  of  the  hepatic 
flexure  the  drawn  membrane  particularly  angulates  the  contained  colon." 

(4)  The  Genitoynesenteric  Fold  of  Douglas  Reid. — This  is  a  fold  of  peritoneum 
frequently  found  in  the  fetus,  which  extends  from  the  mesentery  of  the  terminal 
segment  of  the  ileum  do^vn  into  the  pelvis,  being  attached  in  the  fetus  to  the 
genital  gland  below.  It  has  also  been  termed  by  other  observers  the  "appendic- 
ulo-ovarian  ligament"  (see  page  145).  It  is  occasionally  seen  during  abdominal 
operations,  and,  aside  from  its  possible  connection  with  Lane's  kink,  sometimes 
is  of  clinical  interest  by  causing  a  retroversion  of  the  uterus.  Reid  ascribes  to 
this  connection  between  the  appendix  and  aclnexal  regions  the  frequent  associa- 
tion of  inflammatory  processes  between  the  two.  We  have  looked  for  the  per- 
sistence of  this  fold  in  the  course  of  abdominal  operations  extending  over  about 
twelve  years  and  have  occasionally  observed  it.  Eastman  has  found  it  in  a  very 
considerable  percentage  of  cases  in  fetuses  after  the  seventh  month  and  has 
also  observed  it  in  the  adult. 

(5)  Attic  Adhesions. — Adhesions  about  the  gall-bladder  and  pyloric  region 
are  found  with  very  great  frequency,  as  any  surgeon  who  makes  a  routine 
practice  of  examining  this  part  of  the  peritoneal  cavity  during  pelvic  or  other 
abdominal  operations  can  testify.  Alorris  has  given  the  name  of  "attic  adhe- 
sions" to  these  structures. 

Lane's  kink,  or  ileopelvic  hand,  relates  to  a  membranous  attachment  pass- 
ing from  the  ileum  to  the  parietal  wall  at  a  point  near  the  ileocecal  junction, 
frequently  causing  a  sharp  angulation.  This  is  a  structure  noted  in  the  adult. 
Eastman  calls  attention  to  its  similarity  to  the  genitomesenteric  fold  of  Douglas 
Reid,  and  suggests  that  it  may  be  a  persistence  of  this  fetal  membrane. 

Numerous  other  bands  are  described  in  various  parts  of  the  abdominal 
cavity,  involving  the  appendix,  pancreas,  liver,  stomach,  and  descending  colon. 

The  clinical  significance  of  all  these  various  intra-abdominal  bands  Hes  in 
their  tendency  to  obstruct  the  alimentary  canal  and  cause  s\Tnptoms  and 
conditions  of  stasis. 

The  theories  advanced  to  explain  their  existence  may  be  divided  into  three 
classes:  (1)  That  which  assigns  a  fetal  origin  to  them;  (2)  that  which  explains 
them  as  a  result  of  a  postnatal  inflammatory  reaction;  and  (3)  that  which  asserts 
that  they  represent  a  non-inflammatory  reaction  on  the  part  of  nature  to  resist 
the  ptosis  of  the  abdominal  viscera  resulting  from  man's  erect  posture. 

Those  who  believe  in  the  prenatal  origin  of  these  bands  point  to  the  close 
similarity  that  exists  between  certain  well-defined  fetal  structures  and  the  mem- 
branes discovered  in  adult  life,  as  is  seen,  for  example,  in  the  resemblance  of  the 


lU 


GYNECOLOGY 


parietocolic  fold  of  Jonnesco  to  Jackson's  membrane.     The  origin  of  the  fetal 
merabra,nes  has  not  been  satisfactorily  explained,  but  it  is  known  that  at  an 


Fig.  25. — Abdominal  Bands. 
The  drawing  shows  Lane's  kink,  Jackson's  membrane,  adhesions  of  the  hepatic  flexure,  adhe-' 
sions  about  the  gall-bladder  and  pylorus,  adhesions  of  the  splenic  and  sigmoid  flexures,  and  adhe- 
sions of  the  sigmoid  to  the  left  broad  ligament.    The  small  intestine  and  omentum  have  been  omitted 
from  the  drawing  for  the  sake  of  illustration. 

early  stage  of  fetal  life  the  entire  abdomen  is  filled  with  bands  similar  to  those 
seen  after  an  attack  of  peritonitis,  and  that  toward  the  close  of  fetal  life  they 


RELATIONSHIP  OF  GYNECOLOGY  TO  THE  GENERAL  ORGANISM      175 

usually  melt  away  (Bainbridge,  Keith).  It  is  urged  by  the  supporters  of  the 
congenital  theory  of  intra-abdominal  bands  that  these  bands  represent  the  per- 
sistence after  birth  of  certain  of  the  fetal  adhesions  above  described. 

The  adherents  of  the  inflammatory  theory  of  the  origin  of  intra-abdominal 
bands  base  their  assumption  on  an  .inflammatory  reaction  of  the  peritoneum 
covering  the  bowel  induced  by  mild  chronic  infections  of  the  mucosa,  from 
which  the  process  is  transmitted  through  the  wall  (Pitcher,  Gerster).  Others 
(notabl}^  Martin)  ascribe  the  -adhesions  to-  a  traumatic  reaction  of  the  peri- 
toneum resulting  from  overriding  of  comparatively  fixed  portions  of  the  gut 
by  abnormally  movable  viscera.  Jackson  regarded  the  membrane  which  he 
described  as  the  outcome  of  a  chronic  pericolitis.  Coffey  is  also  an  exponent 
of  the  inflammation  theory. 

The  third  theory,  which  assumes  that  the  intra-abdominal  bands  represent 
an  evolutionary  provision  of  nature  to  resist  the  tendency  of  the  viscera  to 
prolapse,  belongs  peculiarly  to  Lane.  He  maintains  that  the  efforts  of  nature 
to  counteract  the  drag  of  the  bowel  results  in  a  hypertrophy  of  its  membranous 
supports,  constituting,  as  Bainbridge  well  puts  it,  a  ''physiologic  response  to  a 
mechanical  demand."  The  bands  or  folds  resulting  from  this  process  are 
termed  by  Lane  "crystallizations  of  resistance"  or  "crystallizations  of  force." 
They  are  designed,  first,  in  their  physiologic  role  to  facilitate  the  drainage  of 
the  bowel.  Later  they  may  come  to  defeat  the  very  object  for  which  they 
were  created,  and  become  material  factors  in  obstruction  and  stasis.  The 
points  where  these  bands  may  form  are  described  by  Lane  as  follows:  (1)  In 
the  third  part  of  the  duodenum  and  at  the  commencement  of  the  jejunum;  (2) 
at  different  points  along  the  terminal  coil  of  the  ileum;  (3)  in  the.ileocecal  region, 
including  the  appendix;  (4)  in  the  region  of  the  hepatic  flexure  and  the  first  part 
of  the  transverse  colon;  (5)  at  the  splenic  flexure;, (6)  at  the  sigmoid  loop;  (7)  in 
the  rectum.  . 

No  one  of  the  causes  which  serve  as  a  basis  for  the  three  preceding  theories 
can  explain  satisfactorily  all  of  the  intra-abdominal  bands,  but  it  is  probable 
that  each  one,  either  independently  or  in  association  with  one  or  both  of  the 
other  two,  plays  a  part  in  the  formation  of  a  certain  number  of  these  struc- 
tures. 

Sjrmptoms. — Intra-abdominal  bands  may  cause  no  symptoms  whatever, 
and  they  may  act,  as  has  been  mentioned  above,  to  prevent  sagging  of  the 
bowel  and  maintain  proper  drainage.  If,  however,  in  association  with  enterop- 
tosis  they  cause  a  retardation  of  the  fecal  contents  the  symptoms  are  those  of 
stasis,  as  described  in  the  section  on  Enteroptosis. 

When  intra-abdominal  bands  unassociated  with  enteroptosis  constrict 
the  bowel  and  cause  symptoms,  the  clinical  picture  is  somewhat  different.  Pa- 
tients of  this  type  may  be  well  formed,  often  well-nourished  in  appearance. 
Symptoms  of  stasis  may  be  in  evidence,  especially  those  of  constipation,  mus- 
cular pains,  and  lack  of  nervous  equilibrium. 


176  GYNECOLOGY 

In  these  patients  localized  pain  plays  an  important  part  in  the  symptom- 
atology and  may  cause  much  difficulty  in  diagnosis.  On  the  right  side  the 
affection  may  simulate  adnexal  disease,  appendicitis,  and  affections  of  the 
kidney,  or,  if  the  pain  is  higher  up,  gall-bladder  disease,  ulceration  of  the  duode- 
num or  stomach.  On  the  left  side  it  may  be  confused  with  adnexal  disease, 
with  cancer,  or  diverticulitis  of  the  sigmoid. 

The  diagnosis  is  made  by  excluding  other  diseases,  but  pre-eminently  by  the 
ic-ray.  In  our  experience  the  expert  rontgenologist  describes  with  astonishing 
accuracy  conditions  that  are  later  verified  by  operation. 

The  treatment  of  constricting  intra-abdominal  bands  that  cause  symptoms 
is  essentially  surgical.  When  enteroptosis  is  also  present  it  should  be  treated 
according  to  the  suggestions  made  in  the  section  relating  to  that  subject.  The 
bands  should  be  released  by  careful  dissection.  Many  of  these  bands  reach 
a  marked  degree  of  hypertrophy  and  constitute  powerful  structures.  This  is 
especially  true  of  those  which  develop  across  the  upper  part  of  the  ascending 
colon,  by  which  the  cecum  and  sometimes  the  duodenum  may  become  very 
much  distended.  Not  only  must  the  main  constricting  bands  be  severed  and 
dissected  away,  but  frequently  adhesions  between  loops  of  intestines'  must  be 
released.  If  raw  surfaces  are  created  by  this  procedure,  an  effort  should  be 
made  to  cover  them  with  peritoneum  if  any  is  available  for  this  purpose.  Some- 
times it  is  advantageous  to  graft  over  the  raw  area  a  piece  of  fat  removed  from 
the  omentum. 

While  performing  an  operation  of  this  kind  it  is  common  to  hear  the  remark 
that  the  operation  is  futile  because  the  adhesions  will  re-form  rapidly.  This 
is  a  mistake,  as  we  have  on  several  occasions  been  able  to  testify  when  the 
abdomen  had  to  be  reopened  for  some  other  cause  at  a  later  date,  the  formerly 
adherent  area  being  surprisingly  clear  of  adhesions.  If  in  cases  of  enteroptosis 
the  release  of  constricting  bands  makes  the  condition  of  ptosis  worse,  provision 
for  the  support  of  the  intestine  can  be  made  by  attaching  it  to  the  parietes  by 
the  methods  suggested  by  Coffey. 

When  intra-abdominal  bands  are  encountered  incidentally  during  the  course 
of  an  abdominal  operation  they  should  be  treated  conservatively,  for  many 
times  it  will  be  found  that  they  act  as  an  efficient  means  of  preventing  ptosis. 
This  is  especially  true  of  the  veil-like  forms  of  Jackson's  membrane.  If  it  is 
evident  that  the  bands  are  constricting  the  bowel,  they  should  be  dissected. 


PART   I.l 
GYNECOLOGIC   DISEASES 


Inflammations 
gonorrhea 

Considering  its  prevalence,  the  intractability  of  its  local  processes,  and  its 
far-reaching  influence  on  the  health  and  bodily  resistance  of  the  individual, 
gonorrhea  in  woman  must  be  regarded  as  one  of  the  most  important  of  gyneco- 
logic diseases.  Because  of  the  greater  complexity  of  the  female  genital  tract 
the  disease  in  woman  is  far  more  varied  and  more  dangerous,  both  to  life  and 
health,  than  in  man. 

Gonorrhea  has  a  unique  standing  among  infectious  diseases  not  only  in 
its  chnical  manifestations,  but  in  the  fact  that  its  specific  organism,  the  gono- 
coccus,  has  certain  special  characteristics  that  differentiate  it  conspicuously 
from  all  the  pathogenic  bacteria. 

The  microscopic  appearance  and  the  morphology  of  the  gonococcus  cannot 
be  dealt  with  in  this  work;  we  are  here  chiefly  interested  in  its  clinical  pecu- 
liarities. 

There  exists  to  the  gonococcus  no  immunity  whatever,  either  from  previous 
attacks,  or  by  individual  resistance,  or  by  hereditary  racial  quahties,  such  as 
belongs  in  some  form  to  most  other  microbic  organisms.  In  some  married 
people  there  appears  at  times  to  be  a  mutual  immunity  to  an  existing  gonor- 
rhea, yet  this  is  only  apparent,  for,  under  favorable  circumstances,  the  infection 
may  hght  up  into  activity  in  either  of  the  pair,  and  is  always  capable  of  imparting 
an  acute  contagion  when  transferred  to  a  third  person. 

The  gonococcus  finds  its  most  congenial  habitat  on  mucous  surfaces,  where 
it  resides  for  the  most  part  superficially  between  the  interstices  of  the  epithelial 
cells.  It  has  little  tendency  to  invade  the  lumina  of  deep-lying  glands,  such  as 
those  of  the  cervix  and  the  vulva,  but  confines  its  activities  to  the  glandular 
ducts.  Nor  does  it  have  a  disposition  to  penetrate  into  the  subcutaneous  con- 
nective tissue  nor  to  invade  the  lymph-  and  blood-channels,  although  rarely  it 
may  do  all  of  these  things.  Thus,  it  is  sometimes  found  attacking  the  joints, 
or  the  tendons,  or  the  valves  of  the  heart,  while  a  few  cases  of  a  general  gono- 
coccus septicemia  have  been  reported. 

The  organism  has  a  special  predilection  for  certain  human  mucous  surfaces, 
and  when  deposited  on  these  grows  immediately  in  the  same  manner  as  do  other 

12  177 


178  GYNECOLOGY 

bacteria  on  their  favorite  culture-media.  No  abrasion  or  injury  of  the  tissue 
surface  is  necessary,  the  normal  uninjured  epithelium  being  sufficient  for  its 
life  and  reproduction. 

When  confined  in  occluded  spaces  like  that  of  a  sactosalpinx,  the  gono- 
coccus  soon  dies,  whereas  in  unrestrained  secretions  it  retains  an  extraordinary 
longevity  and  virulence. 

The  gonococcus  is  exclusively  a  human  parasite.  It  is  not  found  outside 
of  the  human  body,  nor  can  it  readily  be  inoculated  on  other  than  human  tis- 
sues. Moreover,  it  can  be  easily  cultivated  only  on  media  made  from  human 
secretions.  Thus,  it  will  not  grow  on  pure  agar,  but  may  be  cultivated  on  agar 
combined  with  human  blood.  It  will  grow  in  hydrocele  fluid,  ascitic  fluid,  the 
contents  of  ovarian  cystomata,  and  even  in  urine;  but  not  in  bouillon,  animal 
blood-serum,  and  the  other  commonly  used  culture-media. 

Another  characteristic  of  the  gonococcus  is  that  it  is  infectious  only  in  the 
moist  state  and  that  it  grows  only  on  moist  surfaces.  Under  dry  conditions  it 
soon  dies.  Gonorrhea  is,  therefore,  an  almost  purely  contagious  disease,  and 
is  rarely  transferred  indirectly  except  in  the  case  of  young  children.  With 
this  last  exception,  gonorrhea  of  the  genitals  is  transmitted  almost  exclusively 
by  sexual  contact.  Acute  gonorrhea  in  a  woman  may  be  contracted  from  an 
acute  or  chronic  gonorrhea  of  the  man,  and  vice  versa. 

From  a  clinical  standpoint  one  of  the  most  important  characteristics  of  the 
gonococcus  is  its  power  of  latency.  This  does  not  correspond  biologically  to 
the  spore  stage  of  some  other  bacteria.  It  means  that  the  organism  remains 
hving  in  the  human  tissue,  but  is  temporarily  inactive.  It  means  that  the 
patient  has  gonorrhea  without  symptoms.  The  gonococcus,  lurking  as  it  does 
in  the  interstices  between  the  epithelial  cells,  is  comparatively  safe  from  in- 
juries which  do  not  destroy  the  cells,  so  that  it  may  remain  dormant  for  long 
periods  of  time  until  stimulated  into  activity  by  changes  in  the  circulation  of 
the  surrounding  tissue.  The  limit  of  the  period  of  latency  which  the  gono- 
coccus may  possess  is  a  matter  of  conjecture  and  is  placed  by  different  authori- 
ties from  two  to  ten  or  more  years.  Probably  three  or  four  years  is  the  average 
limit  in  man  and  a  somewhat  longer  period  in  woman.  Reports  of  cases  of 
latency  of  twenty-five  and  twenty  years  are  to  be  received  with  doubt. 

The  favorite  lurking  places  for  the  latent  gonococcus  are  in  the  secluded  and 
well-protected  folds  of  certain  tissues  for  which  it  has  a  predilection.  Exam- 
ples of  these  are  the  prostate  gland  in  the  male,  and  in  the  female  the  ducts  of 
the  cervical  and  vestibular  glands,  and  the  rugae  of  the  fining  membrane  of  the 
Fallopian  tubes.  The  latent  germ  may  light  up  into  acute  activity  in  two 
ways:  it  may  either  produce  a  fresh  gonorrheal  attack  in  the  individual  in 
whom  it  has  been  residing  as  a  latent  parasite,  or  it  may  be  transferred  to  an- 
other individual,  and,  finding  there  a  fresh  soil  more  congenial  to  its  growth, 
incite  an  acute  process.  The  condition  that  favors  an  awakening  of  a  latent 
gonorrhea  is  the  bringing  of  fresh  nourishment  to  the  tissue  in  which  it  exists  as 


INFLAMMATIONS  179 

a  result  of  hyperemia,  such  as  may  be  ehcitecl,  for  example,  by  excessive  venery, 
menstruation,  childbirth,  and  ill-advised  pelvic  operations. 

It  is  tills  power  of  latency  which  makes  the  gonococcus  so  treacherous  an 
organism,  and  which  renders  so  futile  the  efforts  to  prevent  the  extensive  ravages 
that  the  disease  makes  on  the  health  of  the  human  race. 

According  to  Amann,  it  is  probable  that  the  gonococcus  does  not  pass 
through  a  true  incubation  time,  but  rather  begins  to  grow  and  multiply  in  a 
very  short  time  after  being  deposited.  The  reaction  in  the  tissues  appears 
within  from  twelve  hours  to  two  days,  and,  according  to  Amann,  never  more 
than  three  days.  Norris,  on  the  other  hand,  gives  an  incubation  period  aver- 
aging three  days  to  a  week. 

The  various  phases  of  gonorrheal  disease  in  woman  are  determined  by  the 
predilection  which,  as  we  have  seen,  the  gonococcus  has  for  certain  surface  tis- 
sues of  the  body.  To  meet  the  requirements  for  the  active  development  of  the 
gonococcus  the  tissue  must  be  soft  and  delicate,  continually  moist,  and  well 
supplied  with  blood.  The  surface  may  be  modified  epithelium,  like  that  of  the 
urethra  or  the  delicate  squamous  epithelium  -of  the  vagina,  -or  it  may  be  cylindric 
mucous  epithelium,  like  that  of  the  endocervix,  or  it  may  be  the  endothehum 
of  the  pelvic  peritoneum  or  the  delicate  epithelium  of  the  conjunctiva. 

The  surface  epithelium  of  the  various  parts  of  the  female  genital  system 
offers  favorable  soil  for  the  growth  of  the  gonococcus,  and  the  infection  of  each 
one  of  these  parts  constitutes  a  special  disease,  which  may  either  exist  as  an  affec- 
tion by  itself  or  be  associated  with  infections  of  other  areas  of  the  genital  system. 

The  parts  of  the  genital  tract  which  may  be  infected  to  a  greater  or  a  less 
extent  are:  (1)  the  vulva  and  vagina  (of  children);  (2)  the  urethra;  (3)  Skene's  or 
para-urethral  glands;  (4)  Bartholin's  glands;  (5)  the  endocervix;  (6)  the  endo- 
metrium; (7)  the  endosalpinx;  (8)  the  ovaries,  and  (9)  the  pelvic  peritoneum. 
An  understanding  of  gonorrhea  in  women  may  best  be  gained  by  a  succes- 
sive study  of  the  infections  of  these  parts,  and  we  will,  therefore,  proceed  to 
consider  the  subject  under  the  following  topics:  (1)  Vulvovaginitis;  (2)  ure- 
thritis; (3)  inflammation  of  Skene's  glands;  (4)  Bartholinitis;  (5)  endocervicitis; 
(6)  endometritis;  (7)  salpingitis;  (8)  ovaritis,  and  (9)  pelvic  peritonitis. 

Extragenitally  the  gonococcus  may  infect  the  anus,  the  mucous  membrane  of  the  rectum, 
the  conjunctiva  of  the  eye,  and  the  mucous  membrane  of  the  mouth  and  nose  of  the  newborn. 
These  infections,  however,  constitute  diseases  which  do  not  come  within  the  scope  of  this 
book,  and  are,  therefore,  only  to  be  mentioned  in  passing.  It  should  also  be  noted  that  the 
gonococcus  has  no  tendency  in  women  to  ascend  into  the  bladder  and  kidneys,  and  that,  there- 
fore, the  urinary  tract,  with  the  exception  of  the  urethra,  ordinarily  takes  no  part  in  a  gonor- 
rheal attack,  no  matter  how  extensive  the  disease  may  be  in  the  genital  system. 

Gonorrhea  in  Children 

Vulvovaginitis. — Primary  gonorrheal  infection  of  the  vulva  and  vagina  is  a 
disease  which  affects  children  or  young  girls  almost  exclusively.     This  is  due  to 


180  GYNECOLOGY 

the  fact  that  the  modified  squamous  epithelium  of  the  vulva  and  vagina  in 
children  and  early  youth  is  soft  and  delicate.  It  is  extraordinarily  susceptible 
to  gonorrheal  infection.  As  the  child  develops  into  adult  life  the  surface 
epithelium  of  the  vulva  and  vagina  becomes  somewhat  cornified  and  more 
resistant,  so  that  in  adult  life  a  primary  infection  of  the  vulva  or  vagina  is  rare. 
In  very  severe  or  badly  neglected  cases  these  parts  may  become  secondarily 
involved  in  the  adult,  but  when  this  occurs  there  is  usually  a  mixed  infection  of 
organisms  other  than  the  gonococcus. 

The  mode  of  infection  of  vulvovaginitis  in  children  is  -often  difficult  to  deter- 
mine. A  few  cases  in  the  lower  strata  of  humanity  can  be  traced  to  depraved 
sexual  practices.  The  children  of  gonorrheal  patients  are  exposed  to  infection 
by  contaminated  towels,  sponges,  and  bed-hnen.  The  iochial  discharge  of  a 
puerperal  woman  in  whom  childbirth  has  lighted  up  a  latent  gonorrhea  is  a  fre- 
quent means  of  infecting  the  child,  for  the  lochia  is  an  extremely  favorable 
medium  for  the  growth  of  the  gonococcus.  Such  sources  of  infection  as  these 
just  enumerated  are  sufficiently  obvious,  but  when  gonorrhea  makes  its  appear- 
ance and  extends  from  child  to  child  in  carefully  regulated  institutions,  such  as 
hospitals  and  schools,  the  mode  of  infection  is  often  puzzling  and  difficult  to 
trace.  In  searching  for  the  cause  of  such  epidemics  it  is  useful  to  remember 
that  the  disease  can  be  transmitted  only  in  the  moist  state. 

The  clinical  picture  of  a  child  with  gonorrheal  vulvovaginitis  shows  much 
swelling  and  redness  of  the  external  genitals,  associated  with  pain  and  extreme 
tenderness.  The  parts  are  continually  bathed  with  a  profuse  discharge  of  pus. 
The  disease,  like  all  forms  of  gonorrhea,  is  apt  to  last  for  weeks  and  months  if 
not  promptly  treated  at  its  onset.  The  disease  has  little  tendency  to  ascend 
above  the  vagina  into  the  uterus  and  tubes,  but  much  damage  may  be  done  in 
the  vagina  as  a  result  of  the  tendency  to  ulceration  of  the  vaginal  membrane 
with  consequent  plastic  adhesions  between  opposing  surfaces.  This  is  one  of  the 
commonest  causes  of  acquired  gynatresia  (see  page  535).  Various  complica- 
tions may  arise.  In  a  certain  percentage  of  cases  the  urethra  is  infected,  while 
in  a  still  greater  number  the  cervix  becomes  involved.  Other  somewhat  infre- 
quent complications  are  inguinal  adenitis,  cystitis.  Bartholinitis,  condylomata 
acuminata,  arthritis,  ophthalmia,  and  proctitis.  General  peritonitis  is  occa- 
sionally seen,  rarely  the  result  of  upward  extension  through  the  uterus  and 
tubes,  more  commonly  the  outcome  of  a  gonorrheal  septicemia  (Norris) .  Gonor- 
rheal peritonitis  is  peculiarly  favorable  in  its  prognosis,  and,  if  a  diagnosis  can 
be  made,  should  be  treated  conservatively. 

The  treatment  of  gonorrheal  vulvovaginitis  in  children  is  very  difficult  and 
requires  great  care  and  patience.  During  the  acute  stage  there  is  often  so 
much  pain  and  tenderness  that  it  is  impossible  to  do  more  than  keep  the  ex- 
ternal genitals  clean.  Even  this  treatment,  if  properly  carried  out,  requires 
much  constant  attention  and  can  best  be  done  in  a  hospital,  where  care  must 
be  exercised  that  other  children  be  not  contaminated.     When  the  more  acute 


INFLAMMATIONS  181 

process  has  subsided  somewhat  it  is  often  possible  to  inject  protargol,  2.5  to  5 
per  cent.,  or  argyrol,  25  per  cent.,  into  the  vagina  and  to  give  cleansing  douches. 
If  this  can  be  done  in  conjunction  with  rest  and  strict  cleanliness  the  disease 
can  usually  be  quickly  controlled,  though  it  may  be  long  before  it  is  completely 
cured.  It  is  needless  to  say  that  most  of  these  cases  are  badly  neglected  if  they 
do  not  receive  hospital  treatment. 

When  the  disease  appears  in  young  girls  just  past  the  age  of  puberty  in 
whom  local  treatment  is  more  feasible,  it  is  also  best  when  possible  to  put  the 
patient  to  bed  in  a  hospital  under  the  care  of  a  competent  special  nurse.  From 
faur  to  six  hot  cleansing  douches  should  be  given  daily,  while  every  day  or 
every  other  day  an  injection  of  protargol  (5  to  10  per  cent.)  may  be  adminis- 
tered. The  discharge  under  this  treatment  is  quickly  controlled,  but  the 
treatment  should  be  kept  up  for  from  ten  days  to  three  weeks  or  more.  The 
patient  on  returning  home  should  keep  up  the  daily  douches  under  the  super- 
vision of  her  mother  or  a  nurse.  If  the  disease  becomes  recrudescent,  the 
patient  should  receive  again  the  hospital  treatment.  It  is  impossible  to  tell  at 
a  given  time  whether  or  not  one  of  these  patients  is  completely  cured,  as  the 
microscopic  examination  of  the  vaginal  secretion  is  quite  misleading  if  the 
report  is  negative. 

Excellent  results  have  been  reported  from  the  use  of  gonococcal  vaccines, 
which  seem  to  be  more  efficacious  in  the  treatment  of  the  vulvovaginitis  of 
children  than  in  any  other  acute  form  of  gonorrheal  disease. 

Gonorrhea  in  the  Adult 

urethritis 

In  gonorrhea  of  the  adult  the  primary  infection  takes  place  in  the  majority 
of  cases  in  the  urethra.  Just  how  often  this  occurs  is  somewhat  difficult  to 
determine,  and  the  estimates  of  primary  urethritis  vary  from  60  to  90  per  cent. 
This  uncertainty  is  due  to  the  fact  that  the  disease  in  the  urethra  is  often  very 
slight  and  attracts  little  attention  on  the  part  of  the  patient.  As  the  more  serious 
symptoms  of  ascending  gonorrhea  often  do  not  appear  for  several  weeks  or 
months  after  the  primary  urethritis,  the  association  between  the  two  phases 
of  the  disease  may  be  lost.  This  probably  occurs  in  the  majority  of  cases  in 
adults.  Next  to  the  urethra  as  a  point  for  primary  infection,  the  endocervix 
holds  second  place,  while  the  vagina  is  primarily  infected  rarely  except  in  the 
young.  That  the  urethra  should  be  usually  first  attacked  is  logically  to  be  ex- 
pected, for  the  epithelium  of  the  meatus  being,  in  the  female  as  in  the  male, 
an  extremely  favorable  medium  for  the  growth  of  the  gonococcus,  is  the  first 
of  the  susceptible  points  of  the  external  genitals  to  be  exposed  to  infection  during 
coition.  It  often  happens,  of  course,  that  more  than  one  point  may  be  infected 
at  the  same  time.  The  urethra  may  also  be  infected  secondarily  from  a  primary 
focus  in  the  cervix,  and  it  is  probable  that  this  is  often  the  case,  for  the  meatus 


182  GYNECOLOGY 

is  SO  situated  in  the  vestibule  that  leukorrheal  discharge  from  the  vagina  almost 
inevitably  becomes  lodged  to  some  extent  between  the  folds  of  tissue  which 
envelop  the  urinary  orifice.  The  disease  is  usually  confined  to  the  lower  third 
of  the  urethra. 

There  is  no  doubt  that  the  transmission  of  an  acute  gonorrhea  from  the  man  is  more  apt 
to  cause  a  primary  infection  in  the  urethra,  or  in  the  urethra  and  cervix  at  the  same  time,  while 
a  chronic  gonorrhea  of  the  man  might  be  expected  fii'st  to  attack  the  cervix. 

In  the  young,  or  where  the  external  orifice  is  proportionately  small,  the  urethra  is  primarily 
infected,  while  in  those  who  have  borne  children  or  who  have  a  relaxed  vaginal  outlet  the  cervix 
is  more  apt  to  be  first  affected. 

The  picture  of  a  well-defined  gonorrheal  urethritis  is  very  characteristic  and 
almost  pathognomonic.  The  vestibule  is  reddened  and  tender  and  bathed  in 
pus.  The  meatus  is  pouting  and  swollen,  while  from  the  urethra  can  be  ex- 
pressed a  thick  creamy  pus,  a  smear  from  which  shows  the  gonorrheal  diplococci 
in  greater  or  less  abundance.  In  making  a  diagnosis  of  urethritis  it  must  be 
remembered  that  the  reddening  of  the  vestibule  and  the  eversion  of  the  meatus 
may  persist  after  the  urethritis  has  healed,  especially  if  there  has  been  an  as- 
sociated infection  of  Skene's  glands.  Then,  too,  a  vaginitis  or  endocervicitis 
may  cause  a  leukorrhea  which  bathes  the  vestibule,  a  part  of  the  secretion  being 
deposited  in  the  opening  of  the  meatus.  This  leukorrheal  deposit  often  looks 
like  the  pus  from  a  urethritis.  In  testing,  therefore,  for  a  urethritis  it  is  always 
best  to  wipe  the  vestibule  and  meatus  thoroughly  before  attempting  to  express 
pus  from  the  urethra.  Urethritis  may  be  caused  by  the  colon  bacillus  and  other 
organisms,  but  many  cases  of  urethritis  from  this  cause  are  the  result  of  previous 
damage  done  by  a  gonorrheal  infection. 

Symptoms. — As  has  been  noted,  urethritis  in  a  woman  may  come  and  go 
without  producing  any  noticeable  s^^mptoms.  Sometimes  there  may  be  a 
mild  temporary  discomfort  in  urinating  which  is  no  more  severe  than  the  irri- 
tation which  most  women  occasionally  experience  from  a  concentrated  urine. 
A  typical  case  of  urethritis  in  the  female  is  quite  similar  in  its  initial  sj^mptoms 
to  that  in  the  male.  There  is  first  a  sense  of  discomfort  and  then  a  burning 
from  urination,  followed  by  a  purulent  discharge,  which  may  or  may  not  be  ob- 
served by  the  patient.  This  pain  on  urination  is  sometimes  extremely  severe, 
and  may  be  accompanied  by  ulceration  and  bleeding  from  the  urethral  mucous 
membrane.  The  swelling  of  the  external  genitals  often  gives  a  sense  of  pelvic 
pressure,  so  that  the  patient  not  infrequently  consults  her  physician,  thinking 
that  she  has  a  prolapse  of  the  womb.  The  course  of  the  disease,  as  compared 
with  that  in  the  male,  is  less  severe  and  less  definite.  The  duration  of  the  aver- 
age case  is  from  three  to  six  weeks,  but  the  acute  symptoms  usually  last  only  a 
few  days.  The  disease  has  little  tendency  to  ascend  in  the  urinary  tract  unless 
carried  up  by  improper  local  treatment.  Occasionally  gonorrheal  urethritis 
persists  and  becomes  chronic,  but  when  this  happens  there  is  usually  an  associ- 
ated inflammation  of  Skene's  glands,  which  has  an  influence  in  maintaining  the 


INFLAMMATIONS  '  183 

persistence  of  the  urethritis.  Such  a  case  of  chronic  urethritis  may  last  indefi- 
nitely and  be  very  difficult  to  cure.  The  infection  in  time  becomes  mixed,  and 
may  persist  long  after  gonococci  cease  to  appear  in  the  discharge.  Discomfort 
on  urination  continues  to  a  greater  or  less  extent. 

Acute  gonorrheal  urethritis,  as  we  have  seen,  often  heals  spontaneously. 
Many  cases  when  under  observation  do  not  require  local  treatment  of  the 
urethra,  chief  attention  being  directed  toward  preventing  the  disease  from 
ascending  and  attacking  other  parts  of  the  genital  system.  The  local  treatment 
of  urethritis  is  best  carried  out  by  injecting  protargol  (2  to  10  per  cent.)  into  the 
urethra,  care  being  taken  not  to  force  the  solution  into  the  bladder.  The  solu- 
tion should  be  held  in  the  urethra  for  several  minutes  by  pressing  a  pledget  of 
cotton  against  the  meatus.  The  patient  should  urinate  just  before  the  injec- 
tion and  should  abstain  from  urinating  for  an  hour  afterward.  The  solution 
should  be  used  only  in  such  strength  as  the  patient  can  tolerate  without  pain. 
If  the  case  is  taken  in  time,  ascending  infection  can  usually  be  prevented  by  un- 
remitting cleanliness,  chiefly  in  the  form  of  frequent  vaginal  douches. 

The  treatment  of  chronic  urethritis  is,  for  the  most  part,  devoted  to  the 
inflammation  of  Skene's  glands,  which  usually  accompanies  and  maintains  the 
condition. 

Stricture  of  the  urethra  as  a  result  of  gonorrhea  is  not  common  in  women 
because  of  the  comparative  mildness  of  the  disease  and  the  slight  permanent 
damage  usually  done  to  the  urethral  mucous  membrane.  The  symptoms  of 
stricture  are  like  those  in  man — i.  e.,  frequent  and  difficult  micturition  and 
sometimes  incontinence.  Strictures  usually  yield  readily  to  treatment,  which 
consists  either  in  slow  dilatation  without  anesthesia  or  in  forcible  dilatation 
under  an  anesthetic. 


INFLAMMATION   OF   SKENE'S    GLANDS 

Skene's  glands  are  small  secretory  structures  situated  on  each  side  of  the 
meatus,  their  function  being  probably  that  of  lubrication,  though  this  has  not 
been  clearly  established.  The  ducts  of  these  glands  have  minute  exits  near  the 
meatus  which  simulate  the  duct-openings  of  Bartholin's  glands  at  the  introitus 
of  the  vagina.  There  is  also  a  third  gland,  described  by  Schuller,  which  lies 
anteriorly,  half-way  between  the  other  two.  It  is  probable  that  Skene's  glands 
may  be  primarily  attacked  by  gonorrhea,  but  their  infection  is  usually  second- 
ary to  a  urethritis.  An  inflammation  of  them  is  one  of  the  stigmata  of  gonor- 
rhea, for  they  are  rarely  infected  specifically  by  any  other  organism. 

Skene's  glands  when  inflamed  cause  the  meatus  to  look  swollen  and  red. 
The  ducts,  which  are  normally  hardly  discernible,  become  widened  and  exude 
characteristic  gonorrheal  pus.  The  disease  of  the  glands  usually  ceases  with  the 
healing  of  the  associated  urethritis,  but  the  process  may  become  chronic  and 
exist  as  an  independent  disease  for  a  long  time.     As  in  other  chronic  gonorrheal 


184  GYNECOLOGY 

processes,  the  infection  in  time  becomes  mixed  and  the  gonococcus  crowded  out 
by  other  organisms.  The  glands  then  remain  as  small  pus-pockets  which  main- 
tain a  constant  irritation  of  the  meatus  and  urethra.  This  condition  is  a  source 
of  worry  and  mental  distress  to  patients,  especialty  if  they  are  awarp  of  the 
original  cause  of  the  trouble. 

Sometimes  the  process  burrows  more  deeply  into  the  tissue  and  creates  a 
chronic  peri-urethral  abscess,  with  an  opening  into  the  urethra  through  which  it 
discharges  pus  either  continuously  or  periodically.  Chronic  inflammation  of 
Skene's  glands  may  produce  granulation,  caruncles,  or  eversion  of  the  urethral 
lining  membrane.  Sometimes  the  process  causes  permanent  destruction  of  the 
meatus,  so  that  the  opening  of  the  urethra  is  abnormally  wide,  a  condition  which 
may  result  in  partial  incontinence. 

Inflamed  Skene's  glands  w^hich  do  not  subside  under  treatment  of  the  urethra 
may  be  injected  with  protargol  or  iodin  by  means  of  a  blunt-pointed  hypodermic 
needle.  The  long-standing  cases,  especially  those  in  which  permanent  pus- 
pockets  are  established,  require  careful  dissection  and  excision. 

INFLAMMATION   OF  BARTHOLIN'S   GLANDS 

Bartholin's  glands  are  two  racemose  glands,  situated  one  on  each  side  of  the 
posterior  commissure  of  the  vaginal  orifice,  their  physiologic  function  being  that 
of  lubrication.  In  the  virgin  the  openings  are  close  together,  but  in  the  relaxed 
vagina  they  are  more  widely  separated.  The  minute  openings  of  the  ducts  are 
usually  discernible  on  inspection  and  can  be  marked  by  the  two  caruncular 
remains  of  the  hymen,  which  lie  one  on  each  side  of  the  vaginal  opening  and 
which  persist  till  the  membrane  becomes  smoothed  out  by  the  atrophy  of  later 
age.  These  two  ducts  form  useful  landmarks  in  operations  for  repair  of  the  re- 
laxed vaginal  outlet. 

Bartholin's  glands  may  be  infected  primarily,  but  the  infection  is  usually 
secondary  to  an  infection  elsewhere,  especially  in  the  urethra.  They  are  rarely 
infected  by  any  other  organism  than  the  gonococcus,  so  that  an  inflammation  of 
them  constitutes  an  almost  unmistakable  stigma  of  gonorrhea.  The  initial 
infection  takes  place  in  the  short  duct  of  the  gland.  Other  pyogenic  organisms 
in  time  take  part  in  the  inflammatory  process  and  crowd  out  the  gonococcus. 
The  infection  may  then  extend  to  the  main  part  of  the  gland,  and  an  abscess 
be  estabhshed  which  may  become  acute  at  once  or  lie  dormant  to  light  up  at 
some  later  period.  The  initial  infection  may  pass  unnoticed  and  no  evidence  of 
disease  in  the  gland  appear  till  long  after  other  manifestations  of  gonorrhea  have 
disappeared.  As  a  rule  only  one  gland  is  affected,  but  both  glands  may  become 
inflamed,  either  simultaneously  or  at  different  periods. 

Inflammation  of  Bartholin's  glands  is  almost  sure  to  recur  if  the  gland  is  not 
entirely  excised.  This  recurrence  may  take  place  at  any  time  after  the  first 
infection,  often  appearing  years  later.  The  nature  of  the  recurring  inflammation 
may  vary  from  a  slight  thickening  and  tenderness  of  the  gland  up  to  an  enor- 


INFLAMIVIATIONS 


185 


mous  abscess.  The  clinical  picture  of  an  abscess  of  Bartholin's  gland  is  very 
characteristic.  The  swelling  of  the  gland  causes  a  deviation  to  one  side  of  the 
usually  straight  line  of  the  introitus,  and,  on  inspection,  can  readily  be  recog- 
nized at  a  glance.  There  is  exquisite  pain  and  tenderness  in  the  acute  stages. 
On  separating  the  labia  the  parts  appear  red  and  inflamed  and  bathed  in  pus  if 
the  abscess  occurs  during  the  primary  gonorrheal  attack.  The  recurrent  ab- 
scesses are  often  milder  in  their  course. 


Fig.  26. — Bartholin's  Gland. 

Low  power.     General  ^-iew  of  the  structure  consisting  of  glands  of  the  racemose  type  cut  across, 

lying  close  together,  and  in  some  places  dilated.     At  the  top  is  seen  a  duct. 

The  treatment  of  Bartholinitis  is  complete  excision  of  the  gland  whenever  it 
is  possible.  In  the  very  acute  cases  it  is  necessary  first  to  incise  the  abscess  and 
evacuate  the  pus,  and  then  dissect  out  the  gland  as  soon  as  the  wound  becomes 
clean  and  granulating..  In  the  recurrent  tj-pe,  where  the  inflammatory  process  is 
milder,  the  gland  can  be  excised  entire  without  spilling  the  pus  until  the  last  cut 
is  made  across  the  duct.  This  is  preferable  to  evacuating  the  abscess  first, 
because  the  gland  after  being  emptied  collapses  and  the  dissection  of  the  sac  is 
rendered  more  difficult.  A  description  of  the  operation  for  Bartholinitis  is 
given  on  page  588. 


186 


GYNECOLOGY 


Between  the  recurrences  of  inflammation  the  gland  usually  regresses  in  size 
to  such  an  extent  that  it  can  hardly  be  felt  on  palpation.  It  is  better  not  to 
operate  during  this  stage,  as  it  is  difficult  to  find  the  gland  during  dissection  and 
differentiate  it  from  surrounding  tissues.  An  operation  at  this  time  is  apt  to 
result  in  considerable  mutilation,  with  the  possibility  of  leaving  some  of  the 
gland  structure  behind. 

It  sometimes  happens  that  the  inflammatory  process  in  the  gland  entirely 
subsides,  leaving  the  duct  occluded.     Secretions  of  the  glandular  cells  may 


Fig.  27. — Bartholin's  Gland. 
High  power.     From  top  of  same  section  as  previoiis  drawing,  showing  the  duct  which  is  Uned 
by  low  cuboidal  epithehum  and  the  glands  which  are  Hned  by  a  single  layer  of  high  cells  which  secrete 
mucus. 


then  cause  a  retention  cyst.  This  is  a  late  phase  of  Bartholinitis  and  does  not 
appear  until  long  after  the  active  process  has  ceased,  sometimes  many  years 
after.  These  cysts  may  regress  and  then  recur  after  considerable  lapse  of  time, 
or  they  may  become  permanent  and  slowly  grow  into  quite  large  tumors.  They 
do  not  give  much  pain,  but  they  often  interfere  with  coitus  and  sometimes  cause 
urinary  symptoms.  Cysts  of  Bartholin's  glands  are  nearly  always  consequent 
upon  an  old  gonorrheal  infection  and,  therefore,  are  to  be  regarded  as  fairly 
reliable  stigmata  of  the  disease. 


INFLAMMATIONS 


187 


The  treatment  of  Bartholin's  cysts  is  always  total  extirpation  on  account  of 
their  tendency  to  recurrence.  In  operating,  the  incision  should  be  made  through 
the  skin  and  not  through  the  soft  modified  membrane  of  the  introitus  near  the 


r^ 


Fig.  28. —  Cyst  of  Bartholin's  Gland. 
It  shows  the  characteristic  swelling  on  one  side  of  the  introitus.     Abscess  of  Bartholin's  gland  gives 

the  same  outward  appearance. 


duct.  By  careful  dissection  the  cyst  may  be  removed  entire.  If  it  is  punc- 
tured, the  cyst  collapses  and  the  dissection  then  becomes  ragged  and  mutilating. 
It  is  to  be  remembered  that  the  clean  removal  of  a  Bartholin's  gland  or  cyst  is  not 
^  .particularly  easy  operation.     The  dissection  must  be  carried  deeply  into  the 


188 


GYNECOLOGY 


paravaginal  tissues,  and  there  is  often  troublesome  bleeding.     The  operation 
should,  therefore,  not  be  attempted  under  local  anesthesia.     (See  page  589.) 

Another  phase  of  recurrent  Bartholinitis  is  an  inflammatory  thickening  of 
the  gland,  which  gives  considerable  discomfort  or  pain.     The  gland  may  not  be 


Fig.  29. — Large  Cyst  of  Babtholin's  Gland. 
Drawn  from  an  elderly  woman  who  had  carried  the  tumor  for  many  years.     The  vulva  was 
distorted  and  the  cyst  pressed  on  the  urethra  so  as  to  interfere  with  urination.     The  cyst  was  dissected 
out  entire  without  rupturing  it.     There  was  no  connection  with  the  inguinal  canal. 


large  enough  to  be  discernible  on  inspection,  but  can  be  felt  between  the  thumb 
and  forefinger  placed  just  inside  the  introitus.  No  matter  how  small  the  gland 
may  feel,  if  it  is  giving  symptoms  it  should  be  excised,  for  nagging  discomfort 


INFLAMMATIONS 


189 


of  the  perineal  region,  from  whatever  cause,  is  hable  to  be  a  source  of  nervous 
irritation,  which  may  develop  serious  consequences  out  of  all  proportion  to  the 
gravity  of  the  original  lesion, 

ENDOCERVICITIS 

Before  taking  up  the  gonorrheal  infections  of  the  endocervix  and  endometrium  it  is  advis- 
able to  review  briefly  several  important  facts  about  the  structure  of  the  cervix  and  body  of  the 
uterus  which  are  not  always  sufficiently  emphasized.     It  is  a  good  plan  to  regard  the  fundus  and 


Fig.  30. — Glands  of  the  Cervix. 
Low  power.       The  glands  are  shown  in  cross-section.       They  are  lined  by  cylindric  cells,  the 
nuclei  of  which  lie  at  the  base,  leaving  a  large  amount  of  clear  protoplasm.     These  glands  lie  in  the 
connective  and  muscular  tissue  of  the  cervix,  not  having  a  cytogenous  connective  tissue  around  them 
as  do  the  glands  of  the  endometrium. 


cervLx  of  the  uterus  as  two  very  distinct  organs,  which  difTer  from  each  other  more  or  less 
essentially  in  their  histologic  structure,  physiologic  functions,  and  in  the  pathologic  processes 
that  affect  them.  We  shall  have  occasion  often  to  refer  to  this  fact  as  we  proceed  m  the  study 
of  uterine  conditions. 

The  mucous  membrane  of  the  cervix  is  very  different  from  that  of  the  fundus.  In  the 
endocervix  the  membrane  is  composed  of  compUcated  racemose  glands,  with  small  ducts  empty- 
ing into  the  cervical  canal.     The  epithelium  hning  the  cervical  glands  is  of  the  high  cyUndric 


190  GYNECOLOGY 

.  goblet-cell  type.  These  glands  secrete  a  true  mucus,  which,  as  we  shall  see  later,  is  of  great 
importance  in  many  ways.  The  endocervical  mucosa  is  thrown  into  definite  rugae,  radiating 
from  a  central  line,  an  arrangement  commonly  called  the  arbor  vitae.  These  folds  are  of  clinical 
significance  in  inflammatory  processes  of  the  endocervix. 

Toward  the  internal  os  the  mucous  membrane  becomes  modified,  the  glands  become  less 
arborescent,  and  the  high  cylindric  epithelium  becomes  lower  in  type.  At  the  internal  os  the 
mucous  membrane  of  the  cervix  merges  into  the  mucosa  of  the  body  or  the  endometriimi. 

The  endometrial  mucous  membrane  consists  of  simple  tubular  glands  lined  with  a  low  cu- 
boidal  epithelium.  The  surface  epithelium  of  the  canal  is  of  the  same  type,  but  cihated.  The 
endometrium  produces  a  thin  secretion  which  is  not  true  mucus.  We  thus  see  that  the  endo- 
cervix and  endometrium  are  tmhke  both  histologically  and  in  their  physiologic  functions. 
They  also  differ  in  the  manner  in  which  the  same  infection  may  affect  them. 

Normally  the  internal  os  acts  as  an  efficient  barrier  to  all  organisms  excepting  the  gonococ- 
cus,  the  tubercle  bacillus,  and  the  spermatozoon.  If,  however,  the  os  be  artificially  dilated,  or 
if  it  become  patent  as  a  result  of  parturition,  infection  is  possible  from  any  pathogenic  germ. 

Thus  it  is  that  in  the  non-impregnated  uterus  ascending  infection  in  the  endometrium 
and  tubes  rarely  occurs  excepting  from  gonorrhea.  The  endocervix,  however,  is  more  suscep- 
tible to  infection,  as  the  external  os  affords  less  protection  and  the  mucous  folds  of  the  cervical 
mucosa  constitute  a  favorable  soil  for  various  organisms.  Especially  is  this  true  of  the  gono- 
coccus. 

Gonorrheal  infection  of  the  endocervix  may  be  primary  or  secondary.  How 
frequently  it  is  primary  is  a  matter  of  conjecture,  and  opinions  vary  consid- 
erably, some  placing  the  figure  as  low  as  10  per  cent,  and  others  as  high  as  40 
per  cent.  It  is  possible  that  many  of  those  cases  whose  first  noticeable  symp- 
toms are  from  a  salpingitis  have  been  primarily  infected  in  the  cervix.  This  is 
a  reasonable  conclusion,  because  the  cervix  is  one  of  the  most  insensitive  parts 
of  the  body,  and  diseases  of  the  organ,  inflammatory  or  otherwise,  give  little  or 
no  pain.  The  discharge  resulting  from  the  first  infection  may  readily  be  over- 
looked by  the  patient. 

It  is  likely  that  the  endocervix  is  involved  primarily  or  secondarily  in  most 
cases  of  gonorrhea.  Acute  gonorrheal  endocervicitis  in  its  primary  stage  is  not 
often  a  matter  of  special  treatment,  excepting  as  it  occurs  as  a  part  of  a  general 
complex  infection.  When  seen  the  cervix  is  red  and  angry  looking,  with  ever- 
sion  and  prominence  of  the  mucous  membrane.  It  causes  some  pain  to  the 
touch,  and  is  said  in  some  cases  to  be  associated  with  tenderness  of  the  in- 
guinal lymph-glands.  There  is  always  present  a  profuse  gonorrheal  discharge 
mixed  with  mucous  secretions  from  the  cervical  glands.  Menstrual  disturb- 
ances, usually  in  the  form  of  menorrhagia,  are  common. 

Chronic  gonorrheal  endocervicitis,  on  the*i6ther  hand,  is  a  special  disease 
which  is  of  great  clinical  importance  and  one  that  is  very  difficult  to  treat. 
The  process  of  gonorrheal  infection  of  the  endocervical  mucous  membrane 
simulates  that  of  Skene's  and  Bartholin's  glands  in  that  the  infection  occurs 
in  the  ducts  of  the  glands.  Later,  a  mixed  infection  of  other  organisms  takes 
place  gradually  to  the  exclusion  of  the  gonococcus,  and  the  infection  is  then 
carried  into  the  complicated  lumina  of  the  racemose  glands.  The  irritation  of 
the  infection  stimulates  the  mucous  cells  to  a  hypersecretion,  so  that  a  stream 
of  mucopurulent  material  is  continually  poured  out  into  the  cervical  canal. 


INFLAMMATIONS  191 

thus  producing  the  constant  leukorrhea  which  is  so  characteristic  of  the  disease. 
In  some  glands  the  inflammatory  process  may  cause  a  closure  of  the  duct. 
The  gland  continuing  to  secrete  without  an  outlet  becomes  a  retention  cyst. 
This  process  also  takes  place  in  all  chronic  inflammations  of  the  cervix,  wdth 
formation  of  retention  cysts.  They  are  commonly  designated  as  Nabothian 
cysts  from  the  name  of  Naboth,  who  first  described  the  cervical  glands.  Na- 
bothian cysts  are  filled  either  with  clear  mucus  or  with  a  cloudy  mucopus,  if 
the  gland  is  infected. 

Endocervicitis,  unHke  BarthoHnitis,  is  not  a  stigma  of  gonorrhea,  for  it  may 
occur  as  a  result  of  the  lacerations  of  childbirth  or  it  may  even  appear  in  virgins. 
The  endocervix  is  a  favorite  and  treacherous  place  for  the  latent  gonococcus  to 
lurk,  either  in  the  folds  of  the  lining  membrane  or  in  the  ducts  of  the  glands,  ready 
to  fight  up  into  later  infectious  activity  under  the  hyperemic  influence  of  coitus, 
menstruation,  or  childbirth. 

When  a  chronic  gonorrheal  endocervicitis  has  been  established  the  condition 
resembles  somewhat  that  of  gleet  in  the  male.  There  is  a  persistent  irritating 
leukorrheal  discharge  which  the  patient  has  difficulty  in  controlling,  even  with 
numerous  douches.  Douches  have  no  curative  effect  on  the  disease,  as  they  do 
not  reach  the  seat  of  infection.  They  merely  cleanse  the  vagina  of  the  accumu- 
lated secretions  and  prevent  to  some  extent  the  irritation  which  results  from  the 
contact  of  the  discharge  with  the  external  genitals.  The  influence  of  this  con- 
stant leukorrheal  discharge  often  has  a  disastrous  effect  on  the  nervous  system 
of  the  patient,  especially  if  she  is  aware  of  the  original  cause  of  her  trouble. 
She  feels  herself  degraded  by  her  condition  and,  as  her  efforts  for  controlling  the 
disease  are  usually  unavailing,  her  health  becomes  impaired  far  out  of  propor- 
tion to  the  seriousness  of  the  local  infection.  Endocervicitis  must  be  regarded 
as  one  of  the  most  important  factors  in  the  genital  neuroses  which  play  such  a 
prominent  part  in  gynecologic  disease. 

The  treatment  of  endocervicitis  should  be  applied  directly  to  the  endocer\'ix 
itself.  AppHcations  of  tampons  and  painting  the  vagina  and  vaginal  portion  of 
the  cervix,  like  douches,  do  not  reach  the  seat  of  the  disease,  but  serve  only  to 
keep  the  vagina  clean.  It  is  sometimes  possible  to  cure  the  infection  by  repeated 
local  applications  to  the  cervical  canal.  A  quicker  but  not  infallible  method  is 
to  curet  and  cauterize  the  endocervix.  If  all  other  methods  fail,  the  rather  diffi- 
cult Schroder's  operation  of  removing  the  entire  endocervix  may  be  performed. 
(See  page  604.) 

It  is  necessary  to  emphasize  at  this  point  the  fact  that  most  leukorrheal  dis- 
charges from  the  uterus  are  not  from  the  endometrium,  but  from  the  endocervix. 
This  is  of  great  practical  importance  in  the  use  of  the  curet,  which  is  so  often 
improperly  applied  to  the  endometrium  instead  of  to  the  endocervix,  wiiere 
the  real  trouble  lies.  In  this  way  very  frequently  serious  infection  is  carried 
to  the  endometrium,  and  thence  spread  to  the  tubes  and  pelvic  peritoneum. 


192  GYNECOLOGY 


ENDOMETRITIS 


The  endometrium  seems  to  be  peculiarly  immune  to  what  may  be  called  a 
permanent  infection  of  gonorrhea.  It  must  be  that  during  the  process  of  ascend- 
ing from  the  endocervix  to  the  tubes  the  gonococcus  resides  in  activity  on  the 
mucous  membrane  of  the  endometrium  for  a  time,  but  a  true  acute  gonorrheal 
endometritis  is  rarely  seen.  The  conclusion  is  that  the  endometrium  serves  as 
an  efficient  bridge  for  the  passage  of  the  gonococcus  to  the  tubes,  but  that  it  is 
not  a  congenial  soil  for  the  organism  to  make  a  permanent  abiding  place.  This 
fact  is  shown  in  the  microscopic  examination  of  uteri  removed  for  acute  adnexal 
disease,  in  which  usually  the  endometrium  presents  no  sign  of  active  inflamma- 
tion. Gonorrheal  endometritis  is  not,  therefore,  often  a  disease  for  direct  local 
treatment.  If  it  does  occur,  and  can  be  demonstrated,  it  should  either  be  let 
alone  or  treated  with  great  care.  The  curet  is  a  dangerous  instrument  to  use  in 
such  a  case  on  account  of  its  ability  to  extend  the  infection  to  the  pelvic  cavity 
or  of  lighting  up  pre-existing  adnexal  disease.  Moreover,  intra-uterine  applica- 
tions and  douches  are  also  fraught  with  danger. 

In  cases  of  long-standing  pelvic  inflammatory  disease  the  endometrium  is 
sometimes  found  by  microscopic  examination  to  be  in  a  condition  of  so-called 
chronic  endometritis.  (See  page  247.)  This  is  probably  more  often  the  end- 
result  of  puerperal  sepsis  than  it  is  of  acute  gonorrheal  endometritis.  It  may 
cause  abnormal  uterine  bleeding  during  the  recrudescence  of  pelvic  inflammation. 
This  makes  the  conduct  of  the  case  somewhat  confusing,  for  it  often  leads  to  an 
ill-advised  cureting,  which  may  awaken  the  pelvic  process  into  dangerous  activ- 
ity. Persistent  leukorrhea  is  a  constant  symptom  of  chronic  endometritis. 
Dysmenorrhea,  sterility,  and  abortion  are  probably  sometimes  caused  by  it. 

The  treatment  of  chronic  endometritis  is  rarely  directed  to  the  endometrium 
alone,  as  a  diagnosis  is  made  with  such  difficulty.  The  disease  is,  for  the  most 
part,  treated  in  connection  with  chronic  adnexal  disease,  with  which  it  is  usually 
associated. 

GONORRHEA   OF   THE   TUBES 

It  is  seldom  that  an  infection  of  the  tubes  follows  immediately  a  primary 
gonorrheal  urethritis  or  endocervicitis.  The  internal  os,  an  obstructive  barrier 
to  most  microorganisms,  is  less  effective  against  the  gonococcus,  and,  though 
delaying  its  invasion  for  a  time,  may  eventually  allow  it  to  pass  through  and 
attack  the  tubes.  This  may  not  occur  for  months  or  even  years  after  the  initial 
infection,  and  represents  the  awakening  of  a  chronic  latent  endocervicitis. 

The  gonococcus,  on  passing  the  barrier  of  the  internal  os,  proceeds  to  the 
tubes,  doing  very  little  damage  to  the  intervening  endometrium,  which  it  uses 
more  as  a  bridge  than  as  a  soil  for  permanent  propagation.  The  tubal  isthmus, 
though  small  in  caliber,  is  an  open  portal  for  all  fluids  and  organisms  that  pass 
the  internal  os,  so  that  the  gonococcus  finds  ready  access  to  the  tubal  mucosa, 


INFL^^JVIMATIONS 


193 


the  delicate  folds  of  which  are  especially  well  adapted  for  its  implantation  and 
growth. 

Psithology. ^Endosalpingitis. — In  the  earliest  stages  of  the  disease  the  folds 
of  the  mucosa  become  swollen  and  reddened,  while  the  lumen  is  bathed  with  an 
exudate  which  is  more  or  less  purulent,  according  to  the  severity  or  the  duration 
of  the  infection.     The  tube  itself  becomes  elongated  and  thickened;  the  fimbri- 


'-••-/ ~-'^'''<''  ', 


V,     >■-'•     :.vv ';:/-■,,    ••..»''■,    T-*,,-    -"V'.;    -,"-•■,  jv.     \,'.     'o^"* ;  '  /f'  n    ^■>-  !*'■';•; 


jr     :■     ■  1^^     0(1.  <>f    ..  ',        .       I 


Fig.  31. — Normal  Tube.     Middle  Portion. 
Low  power  showing  lumen.     The  lumen  of  the  tube  is  very  nearly  filled  by  folds  of  mucous 
membrane  called  villi.     These  lie  free  in  the  lumen  and  consist  of  a  connective-tissue  stroma  carrying 
blood-vessels.     They  are  covered  with  ciliated,  cylindric  epithelium. 

ated  extremities  are  thickened,  red,  and  angry  looking.  Up  to  this  point  the 
disease  is  a  simple  endosalpingitis  (also  called  catarrhal  salpingitis) ,  and  may  rep- 
resent the  preliminary  stage  of  a  later  and  more  severe  inflammation,  or  it  may 
be  the  limit  of  the  disease.  Both  tubes  may  heal  completely,  or  one  tube  may 
proceed  no  further  in  the  process,  while  the  other  may  go  on  to  destructive 
changes.  There  is  no  doubt  that  both  tubes  are  always  originally  infected. 
In  some  cases  the  endosalpingitis  stage  of  the  disease  seems  hardly  to  be  noticed 

13 


194 


GYNECOLOGY 


by  the  patient,  while  in  others  the  pain  and  tenderness  and  constitutional  reac- 
tion appear  out  of  proportion  to  the  amount  of  anatomic  changes  in  the  tube. 
Pyosalpinx. — As  the  disease  progresses  it  becomes  more  purulent  in  type. 
The  epithelium  of  the  mucosa,  shorn  of  its  cilia  and  rugse  or  folds,  becomes 
ulcerated  and  glued  together.  The  wall  of  the  tube  becomes  thicker  as  the 
inflammatory  process  extends  into  the  muscularis  and  subserosa.  The  tubal 
ostium  becomes  closed,  due  probably  to  retraction  and  agglutination  of  the 


Fig.  32. — Chronic  Salpingitis. 
Low  power.     To  illustrate  the  fusing  together  of  the  villi  of  the  tube  during  an  acute  endosal- 
pingitis.     As  can  be  seen  by  their  fusion,  they  form  spaces  lined  by  tubal  epithelium,  which  are  crlled 
follicles.       The  process  is  now  quiescent,  the  villi  are  not  much  swollen,  though  thickened  in  places 
due  to  the  formation  of  connective  tissue,  and  the  wall  of  the  tube  is  apparently  normal. 

fimbrise,  while  a  closure  also  takes  place  at  the  tubal  isthmus.  In  this  way  a 
pus-sac  is  formed  which  may  grow  to  very  considerable  proportions.  The  pus- 
tube  is  usually  bent  upon  itself  and  becomes  adherent  to  the  posterior  surface 
of  the  broad  ligaments,  though  it  may  adhere  higher  up  in  the  pelvis  to  portions 
of  the  large  intestine  and  to  the  abdominal  wall,  or  to  the  bladder.  With  the 
formation  of  a  pyosalpinx  there  is  always  present  an  associated  inflammation 
of  the  pelvic  peritoneum,  of  the  germinal  epithelium  of  the  ovaries,  and  of  the 


INFLAMMATIONS 


195 


subperitoneal  cellular  tissue,' especially  that  between  the  leaves  of  the  broad 
Hgament.  Pyosalpinx  occasionally  becomes  healed  spontaneously,  but,  as  a 
rule,  it  results  in  permanent  damage  to  the  pelvic  organs  and  peritoneum. 

Tuho-ovaritis. — The  tubal  extremity  may  become  closed  in  another  way 
than  that  described  above.  The  exudate  from  the  tube  naturally  flows  over  the 
surface  of  the  ovary  and  the  fimbrige  readily  become  attached  to  the  ovary,  thus 
closing  the  tubal  exit.     This  is  a  common  way  for  the  tube  to  become  occluded, 


■'.^: 


-""^i^iSv^^ii-^ 


Fig.  33. — Chronic  Follicular  Salpingitis. 
Low  power.     This  shows  well  the  end-result  following  acute  inflammation  of  the  tubal  mucous 
membrane.     The  villi  become  adherent  to  each  other,  fuse,  and  form  the  gland-like  spaces,  called 
follicles,  which  are  seen.      They  are  lined  by  the  epithelium  of  the  tube  and  do  not  extend  into  the 
wall.     The  process  at  this  stage  is  quiescent,  so  that  no  infiltration  with  round  cells  is  seen. 

and  the  result  is  especially  disastrous  because  the  inflammatory  process  may 
include  the  entire  ovary.  In  the  first  method  the  ovary  usually  escapes  with,  at 
most,  only  a  superficial  infection,  but  when  the  end  of  the  tube  is  intimately 
attached  to  the  ovary  the  purulent  process  may  enter  the  substance  of  the  ovary 
itself  and  destroy  a  considerable  part  of  its  tissue.  Ordinarily,  the  albuginea 
layer  of  the  ovary,  which  has  rather  a  dense  structure,  is  resistant  to  infectious 
organisms,  but  when  a  corpus  luteum  forms  and  bursts,  the  ovarian  tissue  over 
the  area  is  temporarily  a  thin,  non-resistant,  practically  necrotic  structure,  con- 


196  GYNECOLOGY 

taining  a  rent  through  which  the  ovum  has  been  expelled.  Moreover,  the 
cavity  of  the  corpus  luteum,  with  its  rich  lining  of  luteal  cells  and  its  blood  con- 
tents, forms  an  excellent  bed  for  the  implantation  of  the  invading  gonococci. 
If  now  the  tube  becomes  engrafted  on  the  surface  of  a  regressive  corpus  luteum, 
the  cavity  of  the  corpus  nisiy  easily  become  involved  with  the  tubal  abscess.  As 
the  abscess  grows  the  containing  sac  is  composed  of  the  tubal  wall  and  stretched- 
out  ovarian  tissue.  This  is  called  a  tuho-ovarian  abscess.  The  ovarian  tissue 
by  this  process  is  never  completely  destroyed,  for  even  if  both  ovaries  are  im- 


FiG.  34. — Chroxic  Salpingitis. 

Low  power  of  a  part  of  the  villi.     The  follicles,  gland-like  spaces  formed  by  fusion  of  the  villi,  are  well 

shown.     There  is  edema  of  the  stroma  and  a  marked  infiltration  with  round  cells. 

plicated  in  an  inflammation  of  this  kind,  no  matter  how  extensive,  ovulation 
and  menstruation  do  not  cease.  The  ovary,  however,  is  permanently^  damaged 
and  cannot  be  restored  to  its  former  condition.  The  progress  of  a  tubo-ovarian 
abscess  is  the  same  as  that  of  a  sactosalpinx,  excepting  that  its  course  is  apt  to 
be 'more  severe. 

Hydrosalpinx. — One  of  the  manifestations  of  gonorrheal  salpingitis  is  a  cystic 
condition  of  the  tube  due  to  closure  of  the  ostium,  the  wall  being  thinned  out 
into  a  translucent  membrane,  and  the  contents  consisting  of  a  clear  serous  fluid. 
This  is  termed  "hydrosalpinx"  or  "sactosalpinx  serosa."    It  was  formerly  believed 


INFLAMMATIONS  ^  197 

that  the  condition  is  an  end-result  of  a  tubal  abscess  in  which  the  activity  of  the 
pyogenic  organisms  has  ceased,  and  the  pus  elements  contained  in  the  sac  have 
been  gradually  converted  into  a  clear  fluid.  This  theory  is  no  longer  held,  and 
it  is  now  thought  that  the  process  is  serous  from  the  start.  Norris  states  that 
"most  gonorrheal  hydrosalpinges  result  from  an  inflammation  which  seals  both 
ends  of  the  tube  and  allows  fluid  to  collect  within  the  lumen.  The  mechanism, 
under  these  circumstances,  is  very  similar  to  that  which  produces  a  pyosalpinx, 

V-  -''-iff.  ^il'>.@f 


? 


bZ4\,v-  jis-lt^vi.  #/<-:.? i/.sv 

Fig.  35 — Chronic  Salpingitis. 
High  power.     This  section  is  stained  to  show  the  plasma  ceUs.     These  are  derived  from  lympho- 
cytes (Mallory)  by  a  large  increase  in  the  amount  of  cytoplasm  which  has  basophilic  properties. 
They  are  also  characterized   by  the   excentric  position  of   the  nucleus,  and  may  contain  several 
nuclei.     Their  importance  is  that  they  are  present  in  chronic  inflammation. 

differing  only  in  the  fact  that  the  inflammation  does  not  progress  to  the  stage 
of  pus  formation."  In  other  words,  it  represents  a  mild  and  quickly  aborted 
gonorrheal  infection.  It  is  also  supposed  that  a  hydrosalpinx  may  be  formed 
after  the  active  pus-forming  stage  of  the  disease  as  a  result  of  a  late  sealing 
of  the  tube  when  the  secretion  has  become  serous.  The  change  from  the  old 
belief  that  hydrosalpinx  is  a  converted  pyosalpinx  is  due  to  the  investigations 
of  Menge,  who  was  unable  ever  to  demonstrate  bacteria  in  the  fluid,  and  in  the 
great  majority  of  specimens  examined  could  find  no  evidences  of  inflammation 


198 


GYNECOLOGY 


in  the  tissue  of  the  wall.  This  he  found  always  greatly  thinned,  with  a  lining 
mucous  membrane  which,  though  atrophied  by  pressure,  was  nearly  always 
intact. 

Hydrosalpinx  may  also  be  caused  bj^  a  pelvic  inflammatorj-  process  whose 
origin  is  outside  of  the  tube,  the  closure  of  the  ostium  being  the  result  of  a  peri- 
salpingitis. In  this  way  tuberculosis,  puerperal  infection,  and  appendicitis 
are,  doubtless,  accountable  for  a  certain  number  of  cases.  Pelvic  tumors  which 
cause  pressure  adhesions,  especially  uterine  myomata,  are  also  included  among 
the  causes  of  hydrosalpinx. 

Tvho-ovarian  cysts  may,  theoretically,  be  converted  tubo-ovarian  abscesses. 
It  is  probable,  however,  that  most  of  them  indicate  the  adhesion  of  a  tube  to  an 


Fig.  36. — Acute  Purulent  Salpingitis. 

The  tubes  are  greatly  swollen  and  pus  is  seen  exuding  from  one  of  the  tubal  ends.     The  fimbrlEe  are 

swollen  and  have  not  reached  the  stage  of  adhesion  and  closure. 

ovarian  cyst,  with  the  later  estabhshment  of  a  communication  between  the 
lumen  of  the  cyst  and  that  of  the  tube. 

Hematosalpinx,  denoting  a  confined  hemorrhage  into  the  tubal  lumen,  is,  in 
the  great  majority  of  cases,  the  result  of  an  extra-uterine  pregnancy  or  gynatresia. 
There  is,  however,  no  doubt  that  in  both  pyosalpinx  and  hydrosalpinx  blood- 
vessels in  the  wall  may  be  ruptured  either  by  pressure  or  torsion,  with  consequent 
hemorrhage  into  the  lumen. 

Gonorrhcea  Isthmica  Nodosa. — The  isthmus  of  the  tube  may  be  the  seat  of 
gonorrheal  infection,  which  may  be  localized  at  this  point  or  be  part  of  a  general 
tubal  infection.     The  disease  when  seen  is  usually  chronic,  but  may  be  acute, 


INFLAMMATIONS 


199 


luxneu 


YxxribnoAc^  Enb'- 


Ju\i\cum 


Fig.  37. — Tubo-ovaritis. 

Diagram  showing  how  an  inflamed  tube  may  become  attached  to  the  ovary  and  communicate  its 

infection  to  the  ovary  through  the  opening  of  a  corpus  luteum. 


"i-eft  TviV)0-o\)(xravxv  MbSiWUS  f'- 


L 


"^  Y'G^^Cs.vKiJS 


Fig.  38.- — Right  Tubal  Abscess,  Left  Tubo-ovarian  Abscess. 
On  the  right  is  a  tubal  abscess  distinct  from  the  ovary  which  is  seen  buried  in  adhesions.     On 
the  left  the  tube  and  ovary  are  involved  in  a  common  abscess,  the  ovarian  portion  of  the  sac  being 
represented  with  a  slightly  scarred  surface. 


and  is  characterized  by  a  hard  nodule  in  one  or  both  horns  of  the  uterus,  with 
occlusion  of  the  tubal  canal.  This  form  of  tubal  infection  is  termed  chronic 
interstitial  salpingitis.     A  more  scientific  and  descriptive  name  is  salpingitis 


200 


GYNECOLOGY 


Fig.  39. — Chronic  Tubo-ovaeitis. 
In  this  case  the  tubo-ovarian  masses  became  adherent  to  the  fundus  of  the  uterus.     The  mass 
on  the  left  has  been  unfolded  in  the  manner  that  should  be  employed  during  an  operation  for  pelvic 
inflammation. 


INFLAMMATIONS  201 

isthmica  nodosa.  The  importance  of  this  form  of  salpingitis  is  often  overlooked 
by  surgeons  in  performing  a  salpingectomy  for  gonorrheal  disease  when  they 
simply  amputate  the  tube  at  or  near  the  uterine  cornu.  The  isthmus  of  a  tube 
removed  in  this  way  may  later  give  trouble  as  a  chronic  interstitial  salpingitis, 
or  it  may  even  light  up  into  an  active  abscess  of  considerable  size.  When  a 
salpingectomy  is  to  be  performed  for  gonorrhea  the  tube  should,  therefore,  be 
removed,  isthmus  and  all,  by  a  wedge-shaped  incision  into  the  cornu  of  the 
uterus. 


Fig.  40. — Hydrosalpinx. 
Low  power.  The  lumen  of  the  tube  is  seen  to  be  dilated.  The  villi  have  been  inflamed,  have 
formed  follicles  by  fusion,  and  are  seen  as  a  gland-like  layer  around  the  inside  of  the  tube.  The  wall 
of  the  tube  is  thickened,  as  is  the  mesosalpinx,  which  extends  down  toward  the  left  lower  corner.  This 
is  an  early  stage,  so  that  the  mucous  membrane  of  the  tube  is  not  compressed  and  the  wall  of  the  tube 
is  not  thinned  out. 

Pelvic  Peritonitis. — All  cases  of  gonorrheal  salpingitis  are  accompanied  by  a 
greater  or  less  degree  of  pelvic  peritonitis.  This  is  necessarily  so  because  the 
serous  or  purulent  exudate  from  the  tube  inevitably  flows  from  the  fimbriated 
extremity  and  infects  the  peritoneal  surface  with  which  it  comes  in  contact. 
The  inflammation  of  the  peritoneum  produces  a  destruction  of  the  epithehum  of 
the  peritoneum,  with  consequent  gluing  together  of  contiguous  surfaces  by  ad- 
hesions. These  adhesions  are  at  first  light  and  filmy  and  are  easily  broken  up, 
but  in  the  course  of  weeks,  months,  or  years  they  gradually  become  more  and 
more  firm,  until   at   last  they  are  exceedingly  tough  and  unyielding.     They 


202 


GYNECOLOGY 


also  contract  and  produce  serious  dislocations  of  the  pelvic  organs.  Pelvic 
adhesions  resulting  from  gonorrheal  salpingitis  are  of  immense  clinical  impor- 
tance, and  patients  suffering  from  this  complication  constitute  a  very  large  per- 
centage of  the  cases  met  with  in  a  gynecologic  clinic. 

The  condition  of  adhesions  following  salpingitis  is  commonty  termed  chronic 
pelvic  inflammation,  or  chronic  pelvic  inflammatory  disease.  In  order  to  under- 
stand fully  the  clinical  and  surgical  aspects  of  chronic  pelvic  inflammatory  dis- 
ease it  is  necessary  at  this  point  to  consider  the  antomic  changes  which  adhesions 

usually  make  in  the  pelvis.  When  one  first 
operates  on  a  severe  case  the  pelvic  organs  seem 
to  be  in  a  hopelessly  confused  tangle,  and  an  in- 
experienced operator  is  apt  to  get  into  serious 
trouble  in  trying  to  extricate  them.  As  a 
matter  of  fact,  the  adhesions  form  in  rather  a 
definite  manner,  and  if  this  is  kept  clearly  in 
mind,  cases  which  on  first  appearance  seem 
utterly  discouraging,  may  be  disentangled  with 
ease  without  injury  to  the  patient.  The  key- 
note to  the  situation  is  that  the  posterior  culde- 
sac,  or  pouch  of  Douglas,  is  the  lowest  point  of 
the  abdominal  cavity,  whether  the  subject  be 
standing,  sitting,  or  lying,  and  as  a  consequence 
the  fluid  exudates  of  a  pelvic  peritonitis  tend  to 
gravitate  to  this  point.  The  anterior  pouch  of 
the  pelvis  (utero vesical  space),  being  at  a  higher 
level  than  the  posterior,  and  out  of  range  of 
the  discharging  ends  of  the  tubes,  remains  com- 
paratively free  from  infection  except  in  very 
extensive  cases.  It  is  to  be  remembered,  then, 
that  the  infective  process  is  chiefly  in  the  pos- 
terior half  of  the  pelvis.  When  the  adhesions 
form  and  become  organized,  the  tubes  and 
ovaries  are  folded  backward  and  become  ad- 
herent to  the  posterior  leaves  of  the  broad  liga- 
ments and  the  posterior  wall  of  the  uterus  and 
vagina.  They  are  also  drawn  downward  deep 
in  the  pelvis.  The  intestines  adhere  to  the  surfaces  of  the  organs,  and  the 
whole  pelvis  may  thus  become  filled  with  a  conglomerate  mass,  consisting  of 
uterus,  adnexa,  and  bowels,  which  it  sometimes  at  first  seems  hopeless  to 
extricate.  These  cases  are,  however,  almost  never  inoperable  if  the  dissection 
of  the  adhesions  is  carried  out  systematically.  • 

A  practical  point  to  consider  in  the  pathology  of  pelvic  inflammatory  dis- 
ease is  its  relation  to  retroversion  and  retroflexion  of  the  uterus.     Inasmuch  as 


Fig.  41. — An  Unusual  Form   of 

Hydrosalpinx. 

As   a   rule,  hydrosalpinx    has   more 

the  form  of  a  retort. 


INFLAMMATIONS  203 

the  disease  is  usually  confined  to  the  posterior  half  of  the  pelvis,  it  is  natural 
that  the  contraction  of  the  adhesions  should  exert  a  backward  pull  on  the  uterus. 
In  this  way  the  uterus  becomes  firmly  adherent  to  the  bowel  and  adnexa  in  the 
position  of  retroversion.  This  consitutes  the  second  most  common  cause  for 
backward  displacement  of  the  uterus.  The  uterus  may  be  folded  back  on  itself 
into  various  degrees  of  retroflexion.  It  is  possible  that  the  center  of  the  uterus 
may  be  drawn  backward  by  adhesions  without  retroverting  or  retroflexing  the 
uterine  body,  thus  producing  the  position  of  anteflexion.  Adhesions  of  the 
adnexa,  acting  unequally  on  the  sides  of  the  uterus,  may  produce  a  lateral  version. 

Symptomatology  of  Acute  Salpingitis. — The  symptomatology  of  acute  sal- 
pingitis is  very  varied.  We  see  many  cases  with  severe  symptoms,  but  with  very 
little  anatomic  change  in  the  tubes,  while,  on  the  other  hand,  we  frequently  en- 
counter extensively  destructive  changes  in  the  adnexa  in  patients  who  have  only 
mild  symptoms. 

In  many  cases  of  salpingitis,  especially  in  mature  women,  symptoms  of  the 
initial  infection  of  the  external  genitals  may  be  entirely  lacking,  so  that  it  is 
often  impossible  to  tell  the  duration  of  the  disease.  In  young  women  gonorrhea 
pursues  a  more  typical  course  than  it  does  in  mature  women  on  account  of  the 
greater  dehcacy  and  susceptibility  of  the  tissues.  Such  a  course  would  be  some- 
what as  follows :  Two  or  three  days  after  exposure  by  coitus  the  patient  notices 
a  burning  on  micturition.  This  burning  usually  lasts  only  a  few  days,  but  may 
last  much  longer.  A  purulent  discharge  is  soon  noticed,  and  the  patient  passes 
through  an  attack  of  urethritis  of  greater  or  less  severity.  If  the  attack  of 
urethritis  is  a  mild  one,  as  is  more  often  the  case,  the  patient  will  remember  only 
that  she  had  a  period  of  smarting  urination  associated  with  a  leukorrheal  dis- 
charge. If  Skene's  glands  are  involved,  the  urethritis  symptoms  will  be  more 
marked.  After  the  subsidence  of  the  urethral  symptoms  the  patient  is  troubled 
with  a  leukorrheal  discharge  the  severity  of  which  depends  on  the  care  which 
she  receives.  In  the  course  of  two  or  three  weeks  or  more  (sometimes  less) 
one  of  the  vulvovaginal  glands  may  become  involved  and  an  abscess  develop 
which  is  very  painful  and  brings  the  patient  under  a  doctor's  care.  The  doctor 
treats  the  abscess  by  poultices  or  incision  and  the  abscess  subsides  for  the  time 
being,  only  to  appear  again  at  some  indefinite  period  in  the  future.  The  leukor- 
rheal discharge  continues,  but  changes  somewhat  in  character.  It  loses  its 
creamy  purulent  appearance  and  becomes  more  stringy  and  mucous,  represent- 
ing now  the  discharge  from  an  infected  endocervix.  The  change  in  character 
is  due  to  the  mixture  of  mucus  which  pours  forth  from  the  overstimulated  endo- 
cervical  glands.  Gonococci  become  more  difficult  to  find  in  the  discharge,  and 
many  successive  examinations,  even  when  taken  from  the  endocervix,  may  be 
negative,  a  point  to  be  remembered  when  one  is  trying  to  determine  whether  or 
not  a  patient  is  still  capable  of  transmitting  the  disease.  In  the  course  of  an 
indefinite  period  of  time  (days,  weeks,  months,  or  years)  the  patient'  is  seized 
with  an  attack  of  acute  abdominal  pain,  with  great  tenderness  across  the  lower 


204  GYNECOLOGY 

part  of  the  abdomen.  There  is  moderate  fever,  usually  vomiting  and  constipa- 
tion. The  pain  is  usually  general  across  the  lower  abdomen,  but  it  may  be 
localized  on  one  side.  The  patient  is  compelled  to  go  to  bed  and  summon 
medical  help.  At  the  present  day  the  general  practitioner  recognizes  and  prop- 
erly diagnoses  these  cases  better  than  was  done  a  comparatively  few  years  ago. 
If  the  pain  was  localized  chiefly  on  the  right  the  patient  was  frequently  hurried 
to  a  hospital,  where  her  appendix  was  removed  through  a  McBurney  incision, 
the  true  cause  of  the  disease  not  being  even  then  discovered.  These  attacks 
are  commonly  called  by  the  laity  "inflammation  of  the  bowels." 

The  duration  of  an  attack  of  acute  salpingitis  is  usually  from  one  to  six 
weeks,  and  is  longer  than  the  average  attack  of  appendicitis.  This  fact  is  valu- 
able as  a  guide  in  interpreting  the  history  of  a  patient  who  describes  a  past 
abdominal  attack.  If  she  had  a  right-sided  attack,  from  which  she  was  confined 
to  her  bed  less  than  a  week,  she  may  have  had  either  appendicitis  or  salpingitis, 
the  evidence  being  rather  in  favor  of  the  former.  If,  however,  she  was  confined 
to  her  bed  for  several  weeks  the  preponderant  evidence  is  very  much  in  favor  of  a 
salpingitis. 

Acute  salpingitis  is  not  often  fatal,  especially  if  it  is  the  first  attack  and  tends 
gradually  to  subside.  It  may  even  heal  spontaneously  and  completely,  but  this 
does  not  happen  often.  The  usual  course  is  that  after  the  cessation  of  the 
acute  symptoms  the  disease  becomes  chronic,  lighting  up  at  occasional  intervals 
into  an  acute  activity  of  greater  or  less  severity. 

Rupture  of  a  pyosalpinx  is  a  rare  accident.  LamoureiLx,  in  1912,  was  able  to  collect  only 
27  authentic  cases  in  the  hterature.  The  onset  of  symptoms  is  sudden.  It  is  said  that  some- 
times the  patient  is  conscious  of  the  rupture  of  the  sac.  Pain  ensues,  at  first  locahzed  to  the 
pelvis  and  then  spreading  to  the  entire  abdomen.  AH  the  symptoms  and  signs  of  general 
peritonitis  follow.  Diagnosis  is  difficult,  the  condition  usually  being  regarded  as  a  peritonitis 
from  an  appendicitis,  unless  the  attending  physician  has  been  famiUar  with  the  case  preceding 
the  rupture.  Prognosis  in  these  cases  is  fairly  good  as  compared  with  general  peritonitis  from 
other  causes,  the  mortality  being  about  50  per  cent,  in  cases  that  receive  early  operative 
treatment. 

Probably  the  most  common  form  of  acute  gonorrheal  salpingitis  is  that 
which  represents  an  acute  exacerbation  of  a  chronic  process.  It  does  not  neces- 
sarily mean  that  there  has  been  a  previous  acute  attack,  because,  as  we  shall 
see  later,  salpingitis  may  start  and  continue  for  some  time  without  acute  symp- 
toms. Acute  secondary  salpingitis  is  apt  to  be  more  severe  and  more  destructive 
than  a  primary  attack.  This  is  due  to  the  fact  that  the  preceding  chronic  proc- 
ess has  been  causing  slow  damage  to  the  pelvic  organs,  which  have  become 
permanently  dislocated  and  distorted  by  adhesions.  Thus,  a  tube  which  has 
become  adherent  to  an  ovary  is  more  likely  to  impart  a  destroying  inflammation 
to  the  ovary  than  in  a  fresh  case  where  the  organs  are  normally  separated.  Or, 
again,  if  the  bowel  be  attached  to  the  tube  an  acute  salpingitis  is  liable  to  cause 
such  damage  to  the  wall  of  the  gut  as  to  allow  organisms  to  pass  through  from 


INFLAMMATIONS  205 

the  intestinal  canal  and  take  part  as  a  mixed  infection  in  the  pelvic  inflammatory- 
process.  This  mixed  infection  increases  very  much  the  danger  of  a  fatal  peri- 
tonitis. On  account  of  the  confining  adhesions  in  secondary  salpingitis  it  may 
readily  be  seen  that  there  is  a  greater  tendency  to  the  formation  of  large  abscess 
than  in  the  first  type.  In  the  latter  case  the  active  period  of  the  disease  is  apt 
to  subside  before  the  tubal  ends  become  sealed.  In  the  secondary  type  the  pus 
becomes  confined  at  once  by  unyielding  adhesions  already  formed,  and  thus  is 
produced  more  commonly  the  large  tubal  or  tubo-ovarian  abscesses. 

The  symptoms  and  course  of  a  secondarj^  acute  salpingitis  are  very  similar 
to  those  in  a  fresh  case.  There  is  usually  to  be  had  in  the  secondary  form  a 
history  of  previous  similar  attacks  or  of  a  chronic  pelvic  inflammation.  In  this 
type  of  salpingitis,  as  in  the  first,  the  tendency  of  the  disease  is  to  subside  under 
proper  treatment,  but  the  abscesses  often  become  so  threatening  that  operative 
measures  have  to  be  taken  early. 

Diagnosis  of  Acute  Salpingitis. — There  are  two  distinguishing  features  which 
characterize  all  cases  of  acute  salpingitis,  and  if  these  be  borne  in  mind  the 
diagnosis  is  comparatively  simple.  One  is  the  condition  of  the  abdomen,  as 
shown  by  palpation,  and  one  is  the  condition  of  the  sides  of  the  pelvis,  revealed 
by  bimanual  examination.  The  abdomen  is  very  characteristic.  The  area  just 
above  the  pubes,  such  as  can  be  covered  by  the  whole  hand  laid  transversely,  is 
uniformly  tender  and  rigid,  while  the  abdomen  above  the  umbilicus,  except 
in  extreme  cases,  is  markedly  less  tender  and  less  rigid.  The  area  of  tenderness 
and  rigidity  in  the  lower  abdomen  of  course  corresponds  to  the  well-defined  limits 
of  local  peritonitis  which  characterizes  the  disease.  Vaginal  examination  usu- 
ally reveals  tender  masses  in  the  sides  and  back  of  the  pelvis,  in  which  case  the 
diagnosis  is  practically  obvious.  Sometimes,  however,  definite  masses  cannot 
be  felt,  and  then  one  makes  a  diagnosis  from  a.  well-defined  tenderness  of  the 
adnexa  which  is  almost  pathognomonic.  Real  tenderness  must  be  carefully 
differentiated  from  that  caused  by  inexpert  or  ungentle  vaginal  touch. 

In  making  a  diagnosis  the  patient's  history,  general  appearance,  and  social 
condition  are  of  importance,  but  often  misleading.  Careful  inspection  of  the 
external  genitals  is  of  great  value.  The  presence  of  an  intact  hymen  in  a  doubt- 
ful case  makes  salpingitis  improbable,  but  does  not  entirely  rule  it  out,  in  young 
women.  Gonorrheal  stigmata,  such  as  a  urethritis,  inflammation  of  Skene's 
and  Bartholin's  glands,  throw  the  weight  of  evidence  in  favor  of  salpingitis,  as 
does  also  the  presence  of  gonococci  in  a  vaginal  discharge.  If  evidence  of  exter- 
nal gonorrhea  is  absent,  it  must  be  remembered  that  in  a  first  salpingitis  attack 
the  external  infection  may  have  been  very  mild  or  quite  temporary,  or  the  pri- 
mary seat  of  infection  may  have  been  in  the  endocervix.  In  secondary  salpin- 
gitis the  external  signs  of  gonorrhea  have  usualty  disappeared  long  before. 

In  making  a  diagnosis  of  salpingitis  the  complement  fixation  test  is  sometimes 
useful.  It  is  very  similar  in  principle  to  the  Wassermann  reaction  for  syphilis. 
By  those  thoroughly  familiar  with  the  test  it  is  regarded  as  a  valuable  adjunct  in 


206  GYNECOLOGY 

the  diagnosis  of  gonorrhea.  The  test  cannot  be  used  in  early  acute  cases,  for  it 
is  negative  until  the  third  or  fourth  week  after  the  disease  is  contracted.  Ac- 
cording to  Norris,  in  subacute  or  chronic  gonorrheas  the  percentage  of  positive 
results  is  about  as  high  as  those  afforded  by  the  Wassermann  test  for  syphilis. 

Differential  Diagnosis  of  Acute  Salpingitis. — The  conditions  most  hkely 
to  be  confused  with  acute  salpingitis  are  appendicitis,  extra-uterine  pregnancy, 
twisted  pedicle  cyst,  infected  or  twisted  fibroids,  and  diverticulitis  of  the  sig- 
moid. 

Appendicitis  can  usually  be  readily  distinguished  from  salpingitis  by  the 
location  of  the  pain  and  the  area  of  abdominal  tenderness,  which  in  the  adult 
is  approximately  3  inches  higher  than  the  site  in  which  tubal  symptoms  usually 
appear.  The  pain  of  appendicitis  is  apt  to  start  in  the  epigastrium  before  be- 
coming localized  in  the  right  side,  while  that  of  salpingitis  usually  begins  in  the 
pelvic  region.  This  difference  is,  however,  not  entirely  reliable,  for  the  pain  of 
salpingitis  is  frequently  felt  first  in  the  midabdominal  region.  If  the  inflamma- 
tion of  the  appendix  extends  to  and  includes  the  tube,  as  it  often  does  in  young 
girls,  the  location  of  the  initial  pain  causes  confusion.  In  salpingitis  the  local 
symptoms  are  usually  on  both  sides  of  the  abdomen,  though  they  raay  be  more 
intense  on  either  side.  If  they  are  confined  to  the  left  side,  appendicitis  is  un- 
likely, but  is  not  necessarily  ruled  out.  Palpation  of  the  abdomen  in  most  cases 
gives  definite  information.  In  localized  appendicitis  the  right  rectus  muscle 
shows  involuntary  rigidity,  which  is  either  absent  or  less  marked  in  the  left 
muscle,  and  the  rigidity  is  most  evident  at  McBurney's  point,  especially  if  there 
is  present  also  an  inflammatory  exudate.  On  the  other  hand,  localized  sal- 
pingitis causes  an  even  symmetric  rigidity  of  the  lower  portions  of  both  muscles 
below  the  umbilicus,  though  one  side  may  be  more  tender  than  the  other. 

Bimanual  examination  gives  by  far  the  most  important  information  in  the 
differential  diagnosis,  and  should  never  be  omitted  as  a  routine,  even  if  the  case 
seems  to  be  unquestionably  one  of  appendicitis.  In  uncomplicated  appendi- 
citis the  vaginal  finger  elicits  no  pelvic  tenderness,  while  in  acute  salpingitis 
pelvic  tenderness  is  always  present  and  is  very  characteristic.  In  the  majority 
of  cases  distinctive  masses  may  be  felt  in  the  adnexa.  If  the  hymen  is  un- 
ruptured the  evidence  is  against  salpingitis,  but  does  not  exclude  it,  for  the 
gonococcus  can  gain  access  to  the  tubes  from  the  vulva.  Gonorrheal  stigmata, 
such  as  pus  from  the  urethra,  inflammation  of  Skene's  and  Bartholin's  glands, 
favor  the  diagnosis  of  salpingitis.  An  intact  hymen  often  necessitates  a  biman- 
ual examination  per  rectum.  In  making  a  rectal  examination  it  must  always  be 
borne  in  mind  that  the  uterus  and  cervix  feel  much  larger  than  when  examined 
through  the  vagina. 

If  appendicitis  has  implicated  the  right  tube,  the  diagnosis  is  more  difficult, 
but  even  in  this  case  the  pelvic  tenderness  is  much  higher  up  than  in  a  typical 
case  of  uncomplicated  salpingitis. 

The  onset  of  the  attack  and  its  course  for  the  first  few  days  is  quite  similar 


INFLAMMATIONS  207 

in  the  two  diseases,  but  appendicitis  tends  either  to  become  rapidly  worse,  with 
symptoms  of  peritoneal  extension,  or  it  subsides  in  a  few  days.  Salpingitis,  on 
the  other  hand,  has  little  tendency  to  general  peritonitis,  but  local  symptoms  of 
an  acute  attack  extend  over  a  considerably  longer  period. 

If  general  peritonitis  is  present  the  diagnosis  is  very  much  in  favor  of  ap- 
pendicitis. A  salpingitis  severe  enough  to  cause  general  peritonitis  would  almost 
invariably  show  unmistakable  evidence  of  adnexal  enlargement. 

Between  acute  salpingitis  and  extra-uterine  pregnancy  there  should,  as  a 
rule,  be  no  great  difficulty  in  diagnosis.  The  pain  of  extra-uterine  is  sharper  and 
more  lancinating  than  that  of  salpingitis  and  is  less  constant.  Abdominal 
rigidity  and  tenderness  is  less  marked  than  in  salpingitis  and  may  be  absent  al- 
together. By  vaginal  examination  the  pelvis  may  feel  the  same  in  the  two 
conditions  as  regards  adnexal  enlargement,  but  in  salpingitis  there  is  much 
greater  tenderness  as  a  rule.  A  purulent  vaginal  discharge  or  the  stigmata  of 
gonorrhea  favor  salpingitis. 

In  salpingitis  the  constitutional  symptoms  are  more  severe  and  the  leukocy- 
tosis is.  much  more  significant. 

In  ectopic  the  usual  history  of  a  delayed  period  is  a  very  important,  though 
not  absolutely  reliable,  sign. 

Between  chronic  salpingitis  and  a  pelvic  hematocele  from  ectopic  the  diag- 
nosis is  very  difficult,  as  is  pointed  out  in  the  chapter  on  Extra-uterine  Preg- 
nancy. 

The  symptoms  of  a  twisted  pedicle  cyst  may  be  very  like  those  of  a  sal- 
pingitis, and,  as  there  is  often  an  acute  inflammatory  process  added  to  the  con- 
dition of  torsion,  the  differential  diagnosis  may  be  very  baffling.  The  diagnosis 
is  of  vital  importance  because  torsion  of  a  cyst  demands  immediate  operation, 
while  in  acute  salpingitis  operation  is  usually  to  be  deferred. 

The  history  of  the  case  is  very  valuable,  though  in  both  diseases  there  may 
be  an  account  of  recurring  attacks.  Bimanual  examination  in  the  early  stages 
of  torsion  shows  tenderness  and  a  mass  only  on  one  side  unless  there  happen  to 
be  bilateral  cysts.  At  this  stage,  too,  the  cyst  is  movable  and  distinguishable 
from  the  immobile  mass  of  a  salpingitis.  If  torsion  has  I'esulted  in  infection 
and .  peritonitis,  a  differential  diagnosis  may  be  impossible,  but  patients  who 
have  reached  this  stage  are  very  sick  and  operative  interference  is  palpably 
urgent.  In  case  of  doubt  it  is  always  best  to  operate,  for,  if  torsion  is  present, 
the  life  of  the  patient  may  be  saved,  while,  if  the  disease  is  salpingitis,  operation 
ordinarily  does  no  harm  and  may  even  hasten  the  convalescence. 

What  has  been  said  of  torsion  and  infection  of  cysts  may  be  said  also  of  pe- 
dunculated fibroids. 

Diverticulitis  of  the  sigmoid  may  cause  symptoms  and  present  signs  very 
like  acute  salpingitis.  It  may  more  closely  resemble  tubal  inflammation  than 
appendicitis,  for,  on  account  of  the  mobility  and  length  of  the  sigmoid,  the 
inflammatory  mass  in  which  the  diverticulum  is  involved  may  lie  deep  in  the 


208  GYNEGOLOGY 

pelvis,  so  that  it  cannot  be  distinguished  by  touch  from  an  adnexal  enlargement. 
Diverticulitis  is  confined  to  the  left  side  and  occurs  usually  in- women  beyond 
the  age  in  which  a  salpingitis  is  liable  to  be  contracted.  The  first  case  of  diver- 
ticuhtis  seen  by  the  writer  was  diagnosed  by  him  as  a  pyosalpinx. 

Treatment  of  Acute  Salpingitis. — This  is  usually  expectant  if  there  is  no 
doubt  about  the  diagnosis.  It  consists  in  complete  rest  in  bed,  with  frequent 
hot  vaginal  douches  and  hot  apphcations  to  the  abdomen  for  the  rehef  of  pain. 
As  the  peritonitis  is  hmited  to  the  pelvis  and  has  little  tendency  to  become 
general,  it  is  best  to  keep  the  bowels  open  by  catharsis  and  enemata.  The  leuko- 
cyte count  of  the  blood,  taken  every  two  or  three  days,  is  an  excellent  guide  to 
the  progress  or  subsidence  of  the  disease.  Most  cases  of  acute  salpingitis  sub- 
side partially  or  completely  under  proper  care  and  nursing. 

The  decision  as  to  later  operative  methods  is  determined  by  various  factors. 
If  the  attack  of  salpingitis  is  the  first  one,  and  subsides,  leaving  little  evidence  of 
the  disease  by  bimanual  examination,  it  is  best  not  to  operate,  but  to  keep  the 
patient  under  observation,  for  the  disease  may  possibly  heal  spontaneously. 
Patients  whose  abdomens  are  opened  under  these  conditions  often  show  nothing 
abnormal  in  the  appearance  of  their  pelvic  organs,  even  though  later  they  may 
start  up  a  destructive  pelvic  inflammation.  It  is  best,  therefore,  to  wait  and  see 
whether  other  acute  attacks  ensue,  or  whether  the  organs  are  to  undergo  a  slow 
process  of  chronic  adherent  inflammatory  disease,  or  whether,  perchance,  the 
patient  may  not  get  well  spontaneously.  If  a  first  attack  of  salpingitis  simulates 
closely  an  appendicitis  or  a  twisted  pedicle  cyst  or  an  extra-uterine  pregnancy, 
and  there  is  much  doubt  in  the  mind  of  the  attending  surgeon,  it  is  better  to 
operate  at  once,  for  with  the  last-named  conditions  an  operation  is  usually  impera- 
tive, while  if  the  case  does  turn  out  to  be  one  of  salpingitis  a  properly  performed 
operation  does  little  harm  and  may  hasten  the  convalescence.  If  the  attack  of 
salpingitis  leaves  permanently  damaged  organs,  the  case  comes  under  the  head- 
ing of  chronic  pelvic  inflammation,  to  be  discussed  later. 

If  a  secondary  acute  salpingitis  appears,  the  treatment  is  still  expectant,  but 
somewhat  less  conservative  than  in  the  case  of  a  primary  salpingitis.  Here  the 
damage  to  the  organs  is  usually  more  obvious,  and,  as  a  rule,  operation  is  de- 
ferred only  until  the  more  acute  symptoms  subside.  In  the  average  case  this 
requires  from  ten  days  to  three  weeks.  Sometimes  the  symptoms  do  not  sub- 
side and  an  operation  must  be  done  to  save  the  patient's  life.  This  is  eminently 
so  when  there  is  a  large  pelvic  abscess  whose  course  suggests  a  mixed  infection. 
These  abscesses  may  occur  in  the  primary  attacks,  but  are  more  apt  to  appear  in 
the  secondary  cases,  as  described  above.  Inasmuch  as  the  tubes  are  drawn 
downward  and  backward  by  the  inflammatory  adhesions,  the  abscesses  are  con- 
sequently found,  as  a  rule,  deep  in  the  posterior  culdesac.  As  they  increase 
they  tend  to  point  downward  into  the  vagina,  and  may  be  readily  puncturisd 
from  an  incision  through  the  posterior  wall  of  the  vagina.  This  operation  should 
not  be  used  as  a  routine^  but  may  be  resorted  to  in  extreme  cases.     As  a  rule, 


INFLAMMATIONS  209 

the  operation  of  vaginal  puncture  is  not  necessary.  The  patient  may  be  kept 
under  treatment  of  rest  and  hot  douches  until  the  temperature  and  leukocytosis 
become  normal.  The  patient  is  then  ready  for  operation,  the  nature  of  which 
depends  on  the  extent  of  damage  to  the  pelvic  organs.  In  the  severely  destruc- 
tive cases  it  is  necessary  to  remove  the  adnexa  and  uterus  by  a  supravaginal 
hysterectomy  with  drainage  through  the  vagina.     (See  page  713.) 

Chronic  Pelvic  Inflammation  as  a  Result  of  Gonorrheal  Salpingitis 

Chronic  peMc  inflammation  is  a  disease  which  is  of  the  greatest  chnical 
importance,  both  to  the  speciahst  in  gjTiecology  and  to  the  general  practitioner, 
for  not  only  is  it  of  very  wide  occurrence,  but  its  general  constitutional  results 
are  varied  and  far  reaching.  We  have  seen  in  the  remarks  on  the  pathology  of 
salpingitis  that  the  chronic  stage  consists  in  a  gradual  process  of  pelvic  adhesions 
which  dislocate  and  immobihze  the  genital  organs.  The  symptoms  of  chronic 
pelvic  inflammation  are  due  directly  or  indirectly  to  this  adhesive  process. 
The  chronic  form  of  the  disease  may  ensue  after  an  acute  attack,  or  it  may  de- 
velop gradual^  mthout  a  definite  initial  onset.  This  is  due  to  the  fact  that  the 
first  infection  may  run  a  very  mild  course,  so  as  to  attract  little  attention  on  the 
part  of  the  patient.  The  resulting  adhesive  process  may,  however,  be  consider- 
able and  quite  incommensurate  with  the  mildness  of  the  beginning  of  the  dis- 
ease. It  is  even  possible  for  a  patient  to  have  an  extensive  chronic  pelvic  inflam- 
mation without  any  subjective  S3rmptoms  at  all,  the  condition  being  found 
incidentally  during  an  operation  for  some  other  cause.  UsuaUy,  however,  the 
s^Tiiptoms  are  fairly  definite  and  quite  characteristic.  The  most  constant  is 
pain  in  the  lower  abdomen  on  one  or  both  sides.  This  pain  is  either  continu- 
ous or  frequent,  with  short  intermissions.  It  is  made  worse  by  exertion.  The 
pain  is  usually  not  very  severe  in  character,  but  is  described  as  dull  and  drag- 
ging. Sometimes  it  is  little  more  than  a  continuous  pelvic  discomfort  which  the 
patient  has  difficulty  in  describing.  The  seat  of  the  pain  is  always  low  in  the 
abdomen;  on  the  right  it  is  2  or  3  inches  below  McBurney's  point.  Alhed 
symptoms  are  very  numerous  and  represent  disturbances  of  most  of  the  func- 
tions of  the  body. 

Patients  Tvith  chronic  pelvic  inflammation  look  worn  and  dragged.  Girls 
lose  the  bloom  of  youth  and  appear  prematurely  old.  The  continuous  nagging 
pain  of  the  pelvis  acts  as  a  severe  irritant  to  the  nervous  sj^'stem,  so  that  these 
patients  usually  become  neurotic,  irritable,  introspective,  melancholy,  often 
hysteric.  Digestive  disturbances  are  common.  On  account  of  the  adhesions 
of  the  large  intestine  constipation  and  mucous  colitis  are  frequent.  The  dis- 
turbance of  the  nervous  and  digestive  functions  leads  to  headaches.  Adherent 
masses  in  the  posterior  culdesac,  or  the  backward  dislocation  of  the  uterus,  may 
cause  sacral  backache.  Most  women  with  this  disease  are  sterile,  and  this 
may  be  a  source  of  mental  worry.     Leukorrhea  from  an  associated  endocer\dci- 

14 


210  GYI^ECQLOGY 

tis  is  usually  present  and  aggravates  the  nervous  and  mental  distress.  Bladder 
symptoms  are  sometimes  present,  but  are  not  common,  because  the  disease  does 
not  usually  extend  to  the  anterior  half  of  the  pelvis. 

Disturbances  of  menstruation  are  common  and  are  of  importance.  Some 
of  the  menstrual  abnormalities  of  chronic  pelvic  inflammation  cannot  easily  be 
explained.  Some  think  them  due  to  a  disturbance  in  the  ovarian  secretion,  which 
is  believed  to  preside  over  the  function  of  menstruation.  This,  however,  is  not 
proved.  There  is  usually  dysmenorrhea,  in  the  sense  that  the  pelvic  pains  are 
exaggerated  during  catamenia.     As  will  be  seen  (see  page  516),  this  must  be 


— r5  ,'     »    rri    , 


^T 


Fig.  42. — Chronic  Salpingitis. 
Both  tubes  are  closed  and  implicated  in  adhesions.     Salpingitis  isthmica  nodosa  is  seen  at  the  bases 

of  both  tubes. 

regarded  not  as  an  essential,  but  as  a  secondary,  dysmenorrhea.  It  is  doubtless 
due  to  the  increased  congestion  of  adherent  and  immobilized  organs. 

It  occasionally  happens  that  there  is  a  temporary  amenorrhea.  Patients 
in  this  condition  sometimes  think  themselves  pregnant  and  attempt  abortion, 
with  very  disastrous  results. 

Menorrhagia  and  metrorrhagia  are  not  uncommon,  and  may  lead  to  much 
confusion  in  diagnosis.  For  example,  a  period  of  menorrhagia  may  follow  a 
period  of  amenorrhea.  This  sequence,  in  connection  with  pelvic  pain  and  a 
palpable  mass,  may  cause  a  very  excusable  diagnosis  of  extra-uterine  pregnancy. 


INFLAMMATIONS 


211 


The  abnormal  uterine  bleeding  sometimes  leads  the  attending  physician  to  curet 
the  uterus,  a  dangerous  procedure,  which  too  often  results  in  lighting  up  the 
chronic  process  into  dangerous  activity. 

A  rare  appearance  in  this  disease,  but  one  which  causes  great  apprehension 
on  the  part  of  the  patient,  is  a  sudden  gush  of  a  large  amount  of  water  or  pus 
from  the  vagina.     This  may  occur  periodically,  and  is  due  to  the  sudden  empty- 


Fig.  43. — Pelvic  Adhesions  from  Salpingitis. 

Seen  through  an  incision  with  the  patient  in  the  Trendelenburg  position.     Bladder,  uterus,  tubes,  and 

intestines  are  all  involved  and  matted  together  in  a  mass  of  adhesions. 


ing  backward  of  a  tubal  cyst  or  a  tubal  abscess.  This  condition  is  called  hydro- 
salpinx or  pyosalpinx  profluens.  As  we  have  seen,  the  isthmus  of  the  tube 
ordinarily  prevents  any  backward  flow  of  fluids,  but  it  appears  that  occasionally 
its  valve-like  action  is  incompetent,  and  the  pent-up  serum  of  a  hj^drosalpinx  or 
the  pus  of  a  pyosalpinx  may  discharge  into  the  uterine  canal  and  vagina.  If  this 
occurs  only  when  the  fluid  contents  exert  a  certain  pressure  the  discharge  may 
act  automatically  and  become  periodic. 


212  GYNECOLOGY 

Treatment  of  Chronic  Pelvic  Inflammation. — The  treatment  of  chronic 
pelvic  inflammation  is  either  medical  or  surgical.  Medical  treatment  consists 
in  local  applications  to  the  vagina  designed  to  allay  the  inflammatory  process, 
while  surgical  treatment  consists  in  the  removal  of  organs  or  parts  of  organs  that 
are  permanently  damaged. 

The  time-honored  medical  treatment  is  the  use  of  hot  vaginal  douches  and 
the  apphcation  of  iodin  and  tampons  to  the  vault  of  the  vagina.  We  have 
already  seen  that  hot  douches  are  valuable  in  helping  to  reduce  inflammation  in 
the  more  active  stages  of  the  disease.  They  are  also  valuable  for  relieving  the 
pain  and  congestion  when  the  disease  is  chronic.  Iodin  acts  as  a  counterirri- 
tant  and  vaginal  antiseptic,  while  the  effect  of  tampons  soaked  in  glycerin  and 
ichthyol  is  somewhat  similar  to  that  of  a  poultice.  By  these  means  patients  can 
often  be  temporarily  relieved  of  their  symptoms,  but  apphcations  to  the  vagina 
have  no  permanent  effect  on  the  pelvic  adhesions,  so  that  local  treatment  cannot 
be  regarded  as  a  curative  measure.  In  some  cases,  however,  douches  and 
tampons  relieve  the  patient  to  such  an  extent  that  more  radical  treatment  is 
lumecessary.     The  majority  of  these  patients  come  sooner  or  later  to  operation. 

Chronic  pelvic  inflammation  with  adhesions  is  sometimes  treated  by  the  electric  applica- 
tion of  heat,  the  treatment  being  known  as  diathermy.  It  is  contraindicated  in  the  presence 
of  pus  or  hemorrhage.  Direct-high  frequency  electric  currents  are  apphed  to  the  pelvic 
organs  by  placing  large  electrodes  one  on  the  abdomen  and  the  other  either  on  the  lumbosacral 
region  or  in  the  vagina.  The  heat  is  developed  slowly  and  progressively  and  is  continued 
thirty  to  forty  minutes.  It  is  claimed  that  by  this  method  pain  is  relieved  and  the  organs 
become  freely  movable,  due  to  an  "absorption  of  the  adhesions."  Excellent  results  have  been 
reported  by  Kowarschik,  Keitler,  and  Recasens.  Considering  the  relief  given  in  chronic 
pelvic  inflammation  from  the  time-honored  use  of  hot  douches  the  treatment  seems  logical, 
but  it  is  doubtful  if  an  actual  absorption  of  adhesions  takes  place. 

The  surgical  treatment  of  chronic  pelvic  inflammation  is  either  conservative 
or  radical,  depending  on  various  factors,  such  as  the  amount  of  destruction  of 
the  tissues,  the  age  of  the  patient,  her  social  condition,  etc.  Conservative 
surgery  of  chronic  pelvic  inflammatory  disease  consists  in  saving  as  much  of 
the  pelvic  organs  as  possible.  This  is  often  feasible  because  there  may,  for 
example,  be  irreparable  damage  to  one  tube,  while  the  other  may  have  healed 
completely,  or  one  ovary  may  be  extensively  involved  in  an  adhesive  or  cystic 
process,  while  the  other  may  have  escaped  serious  injurj^,  or  one  portion  of  a 
tube  may  be  comparative^  sound,  while  the  rest  of  it  is  beyond  repair.  Thus, 
various  problems  present  themselves  which  must  be  solved  by  the  ingenuity  and 
experience  of  the  operator.  The  various  combinations  and  devices  for  conserv- 
ative operations  on  the  adnexa  are  described  in  detail  on  pages  757-765. 

When  the  organs  are  damaged  to  such  an  extent  that  conservatism  offers  no 
hope  for  a  cure,  it  becomes  necessary  to  do  a  radical  operation,  which  consists 
in  the  removal  of  the  uterus  and  appendages  by  a  supravaginal  hysterectomy. 
The  decision  as  to  conservatism  or  radicalism  requires  on  the  part  of  the  surgeon 


INFLAMMATIONS  213 

a  wise  judgment  based  on  experience,  a  knowledge  of  pathology,  and  correct 
information  of  the  patient's  clinical  history,  social  condition,  and  personal 
wishes  regarding  the  disposition  of  her  pelvic  organs.  Surgeons  differ  consider- 
ably in  their  ideas  as  to  when  to  be  conservative  and  when  not  to  be.  More- 
over, each  case  must  be  decided  on  its  individual  merits.  Hence,  it  is  impossible 
to  lay  down  an  entirely  satisfactory  code  of  rules  that  will  meet  the  require- 
ments of  every  case.  There  are  certain  general  principles  which  may  serv^e  as 
valuable  guides  in  the  conduct  of  these  cases,  but  the  final  decision  must  rest 
chiefly  on  the  judgment  of  the  operator. 

In  the  first  place,  it  must  be  recognized  that  the  final  clinical  and  pathologic 
results  of  conservative  operations  are  not  as  good  in  the  percentage  of  cures  as 
are  those  of  properly  performed  radical  operations.  This  is  due  to  the  fact 
that  postoperative  adhesions  are  much  more  apt  to  form  after  conservatism.  It 
is  impossible  in  most  cases  to  perform  such  operations  as  salpingectomy,  salpingo- 
oophorectomy,  salpingostomy,  resection  of  the  ovary,  etc.,  without  leaving 
surfaces  which  are  more  than  likely  to  become  adherent.  The  peritoneal 
wounds,  even  with  the  greatest  care,  are  somewhat  ragged,  and  it  is  inevitable 
that  a  considerable  number  of  catgut  knots  and  sutures  must  be  left  exposed  to 
act  as  irritants  to  the  peritoneum.  In  addition  to  this,  much  of  the  pelvic  peri- 
toneum w^hich  has  been  damaged  by  the  breaking  up  of  adhesions  is  necessarily 
left  in  a  condition  favorable  to  the  re-formation  of  adhesions.  This  is  especially 
true  of  the  posterior  w^all  of  the  uterus  and  the  posterior  leaves  of  the  broad 
ligaments.     The  same  is  true  of  the  damaged  surface  epithehum  of  the  ovaries. 

In  the  radical  operation  of  supravaginal  hysterectomy,  on  the  other  hand, 
if  it  is  performed  as  described  on  page  713,  there  is  no  exposure  of  damaged  peri- 
toneal surfaces  except  in  the  deepest  parts  of  the  pouch  of  Douglas,  where  it 
does  practically  no  harm.  The  pelvic  peritoneum  which  comes  in  contact  with 
the  overlying  intestines  and  omentum  after  the  operation  is  only  that  of  the 
anterior  half  of  the  pelvis,  in  which,  we  have  seen,  adhesive  peritonitis  does  not 
usually  take  place,  and  the  peritoneum  is,  therefore,  left  smooth  and  uninjured. 
In  addition  to  this,  only  one  catgut  knot  is  exposed,  and  that  is  in  a  position  where 
it  does  little  harm. 

There  is,  therefore,  a  great  difference  in  the  results  of  the  two  operations  as 
far  as  the  formation  of  postoperative  adhesions  is  concerned,  and,  in  consequence, 
there  is  necessarily  a  difference  in  the  clinical  results.  A  conservative  operation 
nearly  always  relieves  the  patient  partially  or  completely  for  a  time,  but  many 
of  the  patients  in  the  course  of  a  period  of  time  varying  from,  a  few  months  to 
one  or  two  years  begin  to  experience  again  the  old  nagging  pains,  and  a  certain 
number  of  cases  come  again  to  operation.  The  recurrence  of  the  symptoms  is 
due  to  the  slow  re-formation  and  contraction  of  pelvic  adhesions  and  a  repeti- 
tion of  dislocating  and  immobilizing  of  the  organs.  However,  many  patients 
get  entirely  well,  and  the  percentage  of  cures  is  sufficient^  greater  than  that  of 
failures  to  make  the  operation  advisable  under  certain  conditions. 


214  GYNECOLOGY 

Although  the  radical  operation  when  properly  done  has  a  higher  rate  of 
symptomatic  cures  than  has  the  conservative,  there  are  objections  to  the  re- 
moval of  the  pelvic  organs  which  must  be  carefully  considered.  First,  there  is 
the  prevalent  idea  that  such  an  operation  is  usually  followed  by  certain  serious 
and  definite  nervous  symptoms.  This  subject  is  discussed  in  the  section  on 
Neurology,  and  we  see  there  that  this  wide-spread  belief  dates  from  the  time 
when  hysterectomies  were  perform.ed  in  such  a  way  as  to  result  in  pelvic  ad- 
hesions and  prolapse,  two  conditions  which  are  the  chief  causes  of  genital  neuroses. 
The  objection  is  not  a  serious  one  at  the  present  day. 

In  young  women,  whether  married  or  unmarried,  it  is  obvious  that  the 
radical  operation  should  not  be  performed  unless  the  organs  are  so  irreparably 
damaged  that  conservatism  is  no  longer  feasible.  The  reasons  for  conservatism 
in  young  women  are  partly  sentimental  and  social,  but  these  are  so  powerful  that 
conservative  operations  must  be  performed  even  when  there  is  a  considerable 
prospect  of  a  later  operation.  In  addition  to  this  is  the  moderate  percentage  of 
possibility  of  making  the  patient  fecund.     (See  section  on  Sterihty.) 

The  question  of  the  change  of  sexual  feelings  after  castration  is  discussed  on 
page  128. 

The  personal  environment  of  the  patient  is  a  factor  of  the  greatest  impor- 
tance, and  one  with  which  the  surgeon  should  be  thoroughly  famihar  before 
undertaking  an  operation  for  pelvic  inflammation.  For  example,  in  the  case  of 
a  poor  widow  who  has  living  children  depending  on  her  for  care  and  support 
a  radical  operation,  with  its  greater  likehhood  of  a  permanent  cure,  might  be 
advisable,  whereas  in  a  recently  married  woman  of  the  same  age  it  might  be 
unjustifiable.  In  women  approaching  or  past  the  menopause  the  radical  opera- 
tion is  preferable  unless  the  destructive  process  is  comparatively  shght.  When 
one  or  more  conservative  operations  have  been  performed  without  relief  to  the 
patient  the  radical  operation  is  obviously  indicated. 

In  a  large  number  of  cases  the  problem  is  solved  at  once  by  the  fact  that  the 
organs  are  beyond  reasonable  hope  of  repair.  A  radical  operation  is  then  im- 
perative, irrespective  of  age  or  condition.  Sometimes  this  condition  presents 
itself  unexpectedly,  as  the  preliminary  bimanual  examination  may  fail  to  reveal 
the  real  extent  of  the  pathologic  process.  In  such  a  case  the  surgeon  may  be  in 
an  embarrassing  predicament  if  he  has  failed  to  gain  the  consent  of  the  patient 
for  the  removal  of  organs.  It  is,  therefore,  of  the  greatest  importance  that 
before  every  pelvic  operation  where  inflammation  is  suspected  the  situation 
be  explained  to  the  patient,  and  her  consent,  and,  if  she  be  married,  that  of  her 
husband,  be  secured  for  the  performance  of  whatever  operation  the  surgeon 
considers  for  her  best  health  and  welfare. 

SERUM  AND   VACCINES   IN   GONORRHEA 

The  treatment  of  gonorrheal  conditions  by  serum  and  vaccines  has  been  only 
partially  successful.      In  gynecologic  practice  it  may  be  said  that  with  our 


INFLAMMATIONS  215 

present  knowledge  neither  of  these  forms  of  treatment  are  of  use  in  cases  of 
acute  urethritis  or  in  pelvic  inflammatory  conditions,  whether  acute  or  chronic. 
The  best  results  have  been  obtained  in  gonorrheal  arthritis  and  in  the  vulvo- 
vaginitis of  children.  In  the  latter  disease  the  benefits  from  the  use  of  vaccines 
is  so  well  established  that  it  should  alwaj^'s  be  adopted  as  a  specific  part  of  the 
treatment. 

Antigonococcic  serum  is  usually  prepared  from  health}^  rams  that  have  been 
treated  with  gradually  increasing  doses  of  dead  and  live  cultures  of  gonococci. 
The  dosage  is  2  c.c.  of  the  serum,  administered  subcutaneously  for  from  two  to 
five  doses,  with  intervals  of  one  to  five  days,  according  to  the  reaction  produced 
in  the  patient  and  the  behavior  of  the  disease.  The  reaction  in  the  patient 
shows  a  slight  elevation  of  temperature  and  a  feeling  of  malaise.  There  is  some 
redness  and  swelling  about  the  point  of  injection.  A  slight  increase  in  the  dis- 
charge from  the  genital  tract  is  produced  for  the  first  few  days  following  treat- 
ment (Norris). 

Vaccines  are  preparations  of  dead  gonococci  suspended  in  normal  salt  solu- 
tion and  standardized,  so  that  the  number  of  gonococci  to  a  cubic  centimeter  of 
the  salt  solution  is  known.  Autogenous  and  stock  vaccines  are  used;  autog- 
enous vaccines  are  preparations  of  dead  gonococci  that  have  been  obtained  from 
the  patient  and  grown  on  culture-media.  Stock  vaccines  are  obtained  from 
several  cultures  that  have  been  taken  from  as  many  different  individuals,  usually 
about  eight  or  ten  different  strains  being  used.  The  autogenous  are  regarded  as 
somewhat  more  efficacious  than  the  stock  preparations.  The  stock  vaccines 
are  put  up  in  sealed  containers,  each  container  holding  a  known  number  of  dead 
bacteria.  The  vaccines  are  administered  subcutaneously,  four  or  five  doses 
being  the  average  treatment.  The  dosage  begins  with  about  5,000,000  bacteria, 
and  is  increased  up  to  20,000,000  or  more.  The  reaction  is  similar  to  that  from 
the  serum.  The  opsonic  index  is  a  valuable  guide  to  the  dosage,  but  is  rarely 
available  (Norris). 

The  reaction  induced  by  the  injection  of  dead  gonococci  has  been  used  as  a 
sign  of  the  presence  of  gonorrheal  disease.  Its  value  in  practical  diagnosis  has 
not  yet  been  established. 

Wolff  has  reported  excellent  results  in  the  use  of  vaccines  in  40  cases  of  vulvovaginitis. 
He  strongly  urges  the  advantage  of  autogenous  vaccines,  and  recommends  that  no  other  treat- 
ment be  given  except  that  of  ordinary  cleanliness.  The  vaccine  is  injected  hj'podermically, 
the  initial  dose  being  25,000,000  to  50,000,000.  The  injections  are  given  at  intervals  of  five 
to  seven  days  over  a  period  of  about  thirty-five  days. 

GENITAL    TUBERCULOSIS 

:  Tuberculosis  of  the  female  genital  organs  is  confined  chieflj^  to  the  tubes 
and  endometrium.  It  may,  however,  appear  exceptionally  as  an  affection  of 
the  vulva,  vagina,  or  cervix.  In  the  study  of  this  subject  there  have  been  es- 
tablished certain  facts  with  which  it  is  important  to  be  familiar : 


216  GYNECOLOGY 

(1)  It  has  been  shown  by  experiments  on  susceptible  animals  that  pure 
cultures  of  tubercle  bacilli  when  deposited  on  the  surface  of  the  vagina  will 
rarely  grow  unless  there  has  been  a  previous  lesion  of  the  epithehum.  If,  how- 
ever, the  cultures  be  deposited  in  the  horn  of  the  uterus  the  result  is  practically 
always  positive. 

(2)  Although  tubercle  bacilh  have  been  demonstrated  by  experimentation 
in  the  semen  of  males  affected  by  pulmonary  tuberculosis,  it  is  doubtful  if  the 
disease  is  ever  transmitted  by  coitus. 

(3)  The  question  of  heredity  is  an  important  one.  It  has  been  shown  that 
the  mother  may  infect  the  fetus  from  a  distant  focus  through  the  blood  circula- 
tion. It  has  also  been  shown  that  the  fetus  and  placenta  may  be  infected  by 
coitus.  Infections  of  this  kind  must  be  regarded  as  incidental  and  unusual.  The 
inheritance  from  tubercular  parents  is  more  commonly  a  predisposition  to  the 
disease,  in  the  form  of  a  weakness  on  the  part  of  certain  epithehal  structures  in 
resisting  the  invasion  of  the  tubercle  bacillus. 

(4)  Genital  tuberculosis  in  women  is  quite  independent  of  the  urinary  tract 
and  does  not  tend  to  ascend  from  the  former  to  the  latter. 

(5)  It  is  thought  that  genital  tuberculosis  may  ascend  in  the  genital  tract — 
e.  g.,  from  the  cervix  to  the  endometrium,  and  thence  to  the  tubes — but  this 
must  be  very  rare.  There  is,  however,  a  decided  tendency  of  the  disease  to 
descend  from  the  tubes  to  the  endometrium. 

TUBERCULAR   SALPINGITIS 

Tuberculosis  attacks  both  the  mucous  membrane  lining  of  the  tube  (endo- 
salpinx)  and  the  peritoneal  covering  (perisalpinx) .  The  tube  is  an  especially 
favorable  location  for  the  growth  of  the  tubercle  bacillus  as  well  as  for  the 
gonococcus,  on  account  of  its  convoluted  form  and  its  succulent  lining  mem- 
brane. 

Tuberculosis  of  the  tubes,  whether  of  the  endosalpinx  or  the  perisalpinx,  is 
always  bilateral.  It  is  doubtful  if  the  infection  ever  takes  place  primarily  in 
the  tubes,  the  mode  of  infection  being  either  ascending  or  descending,  or  by  the 
hematogenous  route  from  some  distant  focus. 

Ascending  infection  from  a  tuberculosis  of  some  part  of  the  external  genitals 
is  exceedingly  rare,  and  there  is  reasonable  doubt  if  it  ever  occurs.  In  this 
respect  the  progress  of  the  disease  is  in  marked  contrast  to  that  of  gonorrhea. 

.  Descending  infection  originates  from  a  tuberculosis  of  the  peritoneum  or  in- 
testines above  the  tubes.  The  descending  disease  may  affect  either  the  peri- 
salpinx or  the  endosalpinx,  or  both.  When  only  the  perisalpinx  is  involved,  the 
surface  of  the  tube  merely  takes  part  in  a  general  tubercular  salpingitis.  When 
the  endosalpinx  is  involved  the  disease  becomes  specialized. 

The  hejnatogenous  mode  of  infection  in  the  tubes  implies  a  metastatic  growth 
of  tubercle  bacilli  which  have  come  by  the  blood  circulation  from  some  distant 


INFLAMMATIONS 


217 


focus,  usually  in  the  lungs.  In  this  case  the  original  focus  may  become  entirely 
healed,  while  the  new  growth  of  bacteria  may  continue  to  flourish.  The  infec- 
tion may,  therefore,  appear  to  be  primary  in  the  tubes,  whereas  it  is,  in  reality, 
secondary. 

Except  when  the  tubes  take  part  in  an  acute  general  miliary  tuberculosis, 
tubercular  salpingitis  is  always  chronic.  As  we  have  seen,  the  disease  may  be 
either  an  endosalpingitis  or  a  perisalpingitis,  or  both. 


Fig.  44. — Tubercular  Salpingitis. 
High  power  to  show  giant-cells.     The  gland-like  spaces  are  follicles  formed  by  fusion  of  the  villi. 
In  the  center  of  the  drawing  are  four  giant-cells  which  are  characteristic  of  tuberculosis.       The  tissue 
around  them  has  become  necrotic  and  is  infiltrated  with  round  cells,  mostly  of  the  mononuclear 
variety. 

Tubercular  endosalpingitis  somewhat  resembles  in  its  processes  a  gonorrheal 
infection.  The  first  stage  is  catarrhal,  in  that  it  involves  only  a  superficial  inflam- 
mation of  the  mucous  Hning.  The  tubal  ostium  tends  to  close  early  and  the  dis- 
ease may  progress  to  a  tubercular  pyosalpinx.  The  contents  of  a  tubercular  pus- 
tube  consist  of  a  white,  mushy,  cheesy  material  if  the  infection  is  exclusively 
tubercular,  but  a  mixed  infection  in  these  tubes  is  common.  If  the  latter  takes 
place  the  pus-tube  is  then  exactly  like  that  originating  from  gonorrhea.     In  fact, 


218  GYNECOLOGY 

tuberculosis  and  gonorrhea  may  exist  together.  In  pus  tubes  of  this  kind  the 
presence  of  the  tubercle  bacillus  may  sometimes  be  detected  by  miliary  tubercles 
on  the  surface  of  the  tubes.  Often  it  is  only  discovered  by  microscopic  examina- 
tion of  tt^  walls  of  the  infected  tube.  This  similarity  that  exists  between  large 
tubercular  and  gonorrheal  pus-tubes  may  in  some  circumstances  be  of  serious 
domestic  or  medicolegal  importance.  The  later  pathologic  processes  of  a 
tubercular  tube  are  quite  different  from  those  of  gonorrhea.  An  old  tubercular 
tube,  in  which  the  more  active  process  has  ceased,  is  usually  either  caseous  or 
fibrous,  each  of  which  conditions  is  entirely  characteristic.  In  the  former  case 
the  enlarged  tube  contains  a  white  homogeneous  cheesy  mass  which  is  unmis- 
takable, while  in  the  second  case  a  fibrosis  takes  place  which  completely  occludes 
the  lumen  and  leaves  the  tube  a  solid  fibrous  cy finder.  A  third  form  of  end-result 
is  a  hydrosalpinx,  though  this  is  not  common.  There  is  no  doubt  that  genital 
tuberculosis  may  exist  in  fetal  life.  It  is  thought  that  the  rare  cases  of  so-called 
congenital  hydrosalpinx  are  the  outcome  of  a  fetal  tubercular  salpingitis  (Ans- 
pach). 

Tubercular  perisalpingitis  is  manifested  by  the  appearance  of  miliary  tuber- 
cles on  the  peritoneal  surface  of  the  tubes.  This  may  exist  by  itself,'  or  as  a  part 
of  a  tubercular  peritonitis.  It  is  evident  that  a  tuberculosis  of  the  perisalpinx 
may  extend  through  the  ostium  of  the  tubes  to  the  endosalpinx,  and,  conversely, 
tuberculosis  of  the  endosalpinx  may  extend  to  the  perisalpinx,  either  through  the 
ostium  or  by  direct  extension  through  the  tubal  wall. 

Tubercular  salpingitis  is  nearly  always  associated  with  pelvic  adhesions, 
which  in  a  severe  case  may  be  of  extraordinary  density  and  strength,  so  that 
the  adherent  mass  is  absolutely  inextricable.  This  is  in  contrast  to  gonorrheal 
adhesions  of  the  pelvis,  which  are  rarely  inoperable. 

The  symptoms  of  tubercular  salpingitis  unassociatecl  with  a  tubercular  peri- 
tonitis are  the  same  as  those  of  chronic  gonorrheal  salpingitis.  The  condition 
found  by  pelvic  examination  is  also  exactly  the  same,  so  that,  unless  there  is  an 
intact  hymen,  it  is  almost  impossible  to  make  a  definite  diagnosis  of  tubercular 
salpingitis.  The  presence  of  a  tubercular  focus  elsewhere  in  the  body  may  serve 
as  a  guide  to  the  diagnosis,  but  it  is  as  often  misleading.  If  genital  tuberculosis 
is  associated  with  a  general  tubercular  peritonitis  the  diagnosis  may  then  be 
very  obvious. 

The  progress  of  tubercular  salpingitis  is  very  slow  and  insidious.  If  it 
comes  on  early  in  life  it  may  cause  a  local  or  general  hypoplasia  or  under- 
development of  the  individual.  Amenorrhea  is  sometimes  a  result  of  the  dis- 
ease, especially  if  it  has  extended  to  the  endometrium,  while  sterility  is  almost 
inevitable. 

The  treatment  of  tubercular  salpingitis  is  practically  the  same  as  that  of 
chronic  pelvic  inflammation  from  gonorrhea,  except  that  in  young  women  the 
operation  should  tend  more  to  the  radical  operation  of  hysterectomy.  This  is 
due  partly  to  the  fact  that  conservative  operations  are  apt  to  be  followed  by  a 


INFLAMMATIONS 


219 


recurrence  of  symptoms,  and  partly  to  the  fact  that  the  endometrium  is  second- 
arily involved  in  a  large  percentage  of  cases. 

Some  cases,  where  the  pelvis  is  filled  with  a  densely  adherent  mass  involving 
the  intestines,  are  entirely  inoperable,  but  these  inoperable  cases  may  make 
extraordinary  cures  under  proper  hygienic  treatment,  due  to  the  fact  that  chronic 
adhesions,  unlike  those  from  gonorrhea,  often  become  completely  absorbed  and 
disappear  spontaneously. 

As  has  been  shown,  the  diagnosis  of  tubercular  salpingitis  is  nearly  always 
made  after  the  abdomen  has  been  opened. 

Old  shrivelled  up  fibrous  tubercular  tubes  found  incidentally  during  pelvic 
operations  may  be  removed  without  disturbing  other  organs. 

TUBERCULOSIS   OF   THE   UTERUS 

Tuberculosis  of  the  uterus  is  usually  confined  to  the  endometrium,  and  this, 
in  turn,  is  usually  associated  with  and  secondary  to  tuberculosis  of  the  tubes. 


Fig.  45, — Tubercular  Endometritis. 
Low  power.     Around  the  edges  are  dilated  glands  lying  in  an  edematous  stroma.     The  center 
contains  a  tubercle  consisting  of  necrotic  tissue  infiltrated  with  round  cells  and  coataining  several 
giant-cells. 

The  infection  takes  place  by  descending  extension  in  the  manner  mentioned  above. 
It  is  difficult  to  say  how  frequently  tubercular  endometritis  comphcates  tuber- 


220  GYNECOLOGY 

culosis  of  the  tubes,  but  good  authority  estimates  it  as  occurring  in  about  one- 
half  of  the  cases  (Kiistner) .  This  is  a  matter  of  considerable  practical  impor- 
tance in  deciding  the  question  of  a  conservative  or  radical  procedure  when  operat- 
ing on  the  tubes.  Tuberculosis  of  the  endometrium,  as  a  rule,  usually  affects  only 
the  mucous  membrane,  and  usually  appears  microscopically  only  as  scattered 
tubercles  in  the  stroma.  It  may,  however,  become  more  extensive  and  ulcerate 
the  surface.  Rarely  the  process  invades  the  myometrium,  and  may  even  go  so 
far  as  to  convert  the  uterus  into  a  cheesy,  necrotic  mass. 

Tubercular  endometritis  is  not  a  well-defined  disease  by  itself,  and  is  usually 
discovered  only  incidentally  during  a  microscopic  examination  of  uterine  curet- 
ings.  When  symptoms  occur,  the  most  common  is  persistent  leukorrhea.  If 
ulceration  of  the  endometrium  occurs,  there  may  be  bleeding.  Sometimes  there 
is  long-continued  amenorrhea. 

Inasmuch  as  tubercular  endometritis  is  nearly  always  secondary  to  tuber- 
cular salpingitis,  local  treatment,  such  as  cureting  and  antiseptic  apphcations, 
is  futile. 

TUBERCULOSIS   OF   THE   OVARY 

The  ovaries  are  not  infrequently  infected  secondarily  from  a  tubercular 
salpingitis.  A  few  instances  of  isolated  tuberculosis  of  the  ovaries  have  been 
reported  in  which  unquestionably  the  infection  must  have  reached  the  ovary 
by  the  hematogenous  route  from  a  distant  tubercular  focus.  Primary  tubercu- 
losis of  the  ovaries,  like  that  of  the  tubes,  is  extremely  doubtful. 

TUBERCULOSIS    OF   THE   CERVIX 

The  cervix  is  rarely  infected  by  tuberculosis.  When  this  does  occur  the 
infection  is  usually  primary.  The  appearance  is  that  of  an  irregular  ulceration, 
and  it  can  be  distinguished  from  syphihs  or  cancer  or  simple  erosion  only  by 
microscopic  examination  of  an.  excised  specimen. 

VAGINA 

Isolated  tuberculosis  of  the  vagina  is  a  rare  cUsease.  When  it  does  occur  it 
is  usually  found  in  children.  It  manifests  itself  by  irregular  ulcerations  of  the 
vaginal  surface, 

VULVA 

Tuberculosis  of  the  vulva  is  the  same  as  lupus.  It  appears  as  extensive  ul- 
cerations, combined  with  polypoid  hypertrophy  of  the  tissues.  The  disease  may 
extend  over  the  perineum  to  the  anus  and  rectum  and  may  also  spread  into  the 
vagina.  The  ulcerations  are  irregular  and  covered  with  a  shmy  debris.  They 
are  sufficiently  destructive  to  cause  fistulse  in  the  labia. 

Tuberculosis  of  the  vulva  may  simulate  closely  elephantiasis,  syphihs,  esthi- 


INFLAMMATIONS  221 

omene,  and  cancer,  and  the  diagnosis  can  only  be  made  definitely  by  microscopic 
examination  of  an  excised  piece  of  tissue. 

The  treatment  of  tuberculosis  of  the  vulva  is  like  that  for  lupus  elsewhere  in 
the  bodJ^  If  the  disease  has  not  extended  too  far  into  the  surrounding  tissues  a 
vulvectomy  is  often  advisable. 

TUBERCULAR  PERITONITIS 

Tubercular  peritonitis  is  not  classified  strictly  as  a  gynecologic  disease,  but 
it  is  so  closely  associated  with  genital  tuberculosis,  and  cases  are  so  frequently 
seen  in  gynecologic  chnics,  that  it  must  be  considered  here. 

Three  forms  of  tubercular  peritonitis  are  to  be  distinguished: 

In  the  first  form  mihary  tubercles  are  disseminated  over  the  peritoneum  of 
the  abdominal  cavity,  either  generally  or  partially.  There  is  always  ascites, 
which  is  usually  tinged  with  blood.  Adhesions  may  or  may  not  be  present. 
This  type  of  the  disease  is  termed  tubercular  peritonitis  with  ascites. 

The  second  form  is  characterized  by  extensive  adhesions  without  ascites. 
The  intestines,  omentum,  and  mesentery  are  matted  together  in  a  conglomerate 
indistinguishable  mass.  If  the  pelvis  is  involved  the  pelvic  organs  are  imphcated 
in  the  process.  The  adhesions  are  dense  and  inextricable.  It  is  usually  im- 
possible to  free  intestines  bound  together  in  these  masses  without  injuring  their 
walls.  Nevertheless,  the  adhesions  seen  in  this  disease,  hopeless  as  they  may 
appear,  sometimes  entirely  disappear  at  a  later  stage. 

This  type  is  called  dry  adhesive  tubercular  peritonitis.  It  may  be  general  or 
it  may  be  locahzed  in  certain  parts  of  the  abdomen.  The  first  and  second  form 
may  occur  together  in  different  parts  of  the  same  abdomen.  In  fact,  the  second 
type  may  represent  a  later  stage  of  the  first. 

The  third  form  of  the  disease  occurs  as  tuberculous  nodes  agglutinated  in 
masses.  These  masses  tend  to  become  necrotic  and  may  cause  fistulse.  The 
tubercular  nodes  may  form  circmnscribed  annular  masses  around  the  intestines, 
with  corresponding  enlargement  of  the  mesenteric  glands,  a  condition  some- 
times so  closely  simulating  cancer  that  it  may  be  impossible  to  make  a  diagnosis 
excepting  by  the  microscopic  examination  of  the  tissue.  This  type  is  called 
nodidar  tubercular  peritonitis. 

The  symptoms  of  tubercular  peritonitis  vary  somewhat,  according  to  the 
type  of  the  disease.  In  the  first  form  there  may  be  no  well-defined  sjmiptoms 
until  sufficient  fluid  has  collected  in  the  abdomen  to  call  attention  to  the 
location  of  the  disease.  This  is  the  type  that  is  most  often  seen  in  the  young. 
General  constitutional  symptoms  are  first  noticed,  such  as  general  weakness, 
night-sweats,  loss  of  weight  and  sleep,  and  various  digestive  disturbances.  Girls 
are  apt  to  be  amenorrheic  and  to  show  retarded  development.  Attention  is 
called  to  the  ascites  by  enlargement  of  the  abdomen  or  by  dyspnea. 

In  the  second  form  of  the  disease  the  constitutional  symptoms  are  Hke  those 
in  the  first.     There  is  apt  to  be  more  definite  abdominal  pain.     The  adherent 


222  GYNECOLOGY 

masses  may  be  felt  by  palpation  of  the  abdomen  and  resemble  various  tumor 
formations.  On  this  account  cases  of  adhesive  tubercular  peritonitis  are  fre- 
quently encountered  during  exploratory  abdominal  operations. 

Nodular  tubercular  peritonitis  is  clinically  a  much  more  serious  disease  than 
the  other  two  types.  In  this  form  there  is  greater  destruction  of  tissue;  hence, 
abdominal  symptoms  may  be  very  severe.  Blood  and  pus  may  appear  in  the 
stools,  and  the  symptomatology,  like  the  gross  pathology,  may  closely  resemble 
cancer  of  the  intestine. 

The  diagnosis  of  tubercular  peritonitis  with  ascites  is  usually  comparatively 
easy  to  make.  Ascites  in  a  young  person  unassociated  ^vith  heart  or  kidney  dis- 
ease or  edema  elsewhere  in  the  body  usually  means  tuberculosis  of  the  perito- 
neum. If  the  patient  is  in  the  cancerous  age  it  may  be  difficult  to  differentiate 
between  tuberculosis  and  malignant  disease.  The  tubercuhn  test  is  useful  when 
there  is  great  doubt. 

The  diagnosis  of  adhesive  tubercular  peritonitis  is  usually  difficult  to  make 
with  exactness,  especially  if  the  conglomerate  mass  involves  the  pelvis.  These 
masses  are  so  dense  that  they  are  often  mistaken  for  adherent  ovarian  or  fibroid 
tumors.  The  condition  is  especially  hke  the  cancerous  peritonitis  that  results 
from  a  mahgnant  ovarian  cyst.  Even  after  the  abdomen  is  opened  it  may  be 
impossible  to  make  a  diagnosis  from  gross  inspection. 

Nodular  tubercular  peritonitis,  as  has  been  mentioned  above,  is  especially 
hke  mahgnant  disease,  both  from  external  examination  and  after  the  abdomen 
is  opened.  The  diagnosis  of  tubercular  disease  from  inspection  during  opera- 
tion is,  of  course,  simple  if  miliary  tubercles  are  present,  but  in  the  severe  cases 
there  is  often  no  sign  of  them. 

The  treatment  of  tubercular  peritonitis  is  a  subject  of  interest  and  specu- 
lation. In  the  ascitic  cases  the  question  of  operation  arises.  It  was  discovered 
that  many  of  these  cases  recovered  after  an  operation  of  opening  the  abdomen 
and  evacuating  the  fluid.  It  was  supposed  that  these  cures  were  due  to  the 
effect  of  letting  hght  and  air  into  the  peritoneal  cavity.  For  that  reason  many 
surgeons  made  long  incisions  and  exposed  the  peritoneum  as  much  as  possible. 
The  custom  of  operating  on  these  cases  became  general.  It  was  then  discovered 
that  many  cases  got  well  without  operation,  and  at  the  present  time  opinion  as 
to  the  advisability  of  surgical  interference  is  somewhat  divided.  The  light  and 
air  theory  is  not  now  generally  held.  One  theory  as  to  the  benefit  of  opening  the 
abdomen  and  evacuating  the  fluid  is  that  the  disease  is  converted  by  this  means 
into  the  dry  adhesive  form,  which  is  a  more  favorable  stage  for  spontaneous 
heahng.  There  seems  to  be  no  doubt  that  operation  is  sometimes  advantageous, 
while  the  chances  of  doing  harm  are  almost  nil.  When  the  fluid  coUects  to 
such  an  extent  as  to  cause  dyspnea  and  other  discomforts,  evacuation  of  the 
fluid  may  be  imperative.  This  is  best  done  by  a  laparotomy  incision  rather 
than  by  paracentesis  on  account  of  the  possibility  of  adhesions  of  the  intestine 
to  the  anterior  abdominal  wafl.     If  operation  is  performed  the  general  con- 


INFLAMMATIONS  223 

stitutional  measures  for  treating  tubercular  patients  must,  of  course,  also  be 
carried  out. 

The  dry  adhesive  form  of  tubercular  peritonitis  comes  to  light  usually  during 
an  exploratory  laparotomy  following  a  doubtful  or  mistaken  diagnosis.  If  the 
disease  is  confined  mostly  to  the  pelvis,  the  case  may  be  operable,  and  the  pro- 
cedure is  that  described  under  Tubercular  Salpingitis.  If  there  is  considerable 
involvement  of  the  intestines  the  case  is  usually  inoperable,  as  the  adhesions  can- 
not be  separated  without  too  much  bleeding  and  injury  to  the  intestinal  walls. 
These  cases,  hopeless  as  they  look,  are  by  no  means  incurable.  Under  proper 
hygienic  treatment  patients  sometimes  make  the  most  astonishing  recoveries. 
We  have  observed  2  cases  which  came  to  laparotomy  many  years  after  explora- 
tory incisions,  when  the  presence  of  conglomerate  adhesions  made  further 
operation  out  of  the  question.  At  the  time  of  the  second  laparotomy,  one  of 
which  was  for  a  fibroid  and  the  other  for  postoperative  hernia,  the  tubercular 
adhesions  had  almost  completely  disappeared. 

Prognosis. — Opinions  as  to  the  ultimate  prognosis  of  ascitic  and  adhesive 
tubercular  peritonitis  differ  much.  Many  regard  the  outcome  of  the  disease  as 
favorable  in  a  considerable  percentage  of  cases,  while  others  believe  the  final 
prognosis  extremely  bad.  All  agree  that  the  disease  is  rarely  of  itself  fatal, 
but  those  who  take  a  dark  view  of  the  subject  consider  that  most  of  the  patients 
ultimatel}^  die  of  some  other  form  of  tuberculosis.  Our  experience  has  been 
favorable. 

It  should  be  mentioned  incidentally  as  a  warning  that  when  the  abdomen  is 
opened  and  tubercular  peritonitis  of  the  first  two  types  is  found,  the  wound 
should  never  be  drained,  for  if  this  is  done  a  persistent  sinus  is  almost  sure  to 
follow. 

Nodular  tubercular  peritonitis  cannot  easily  be  treated  by  surgery.  The 
condition  is  usually  discovered  on  opening  the  abdomen  for  expected  intestinal 
cancer,  appendicitis,  or  diverticulitis,  etc.  If  the  condition  is  such  as  does 
not  absolutely  require  interference,  like  that  of  intestinal  obstruction  or  abscess 
formation,  it  is  best  to  leave  the  lesions  alone.  Attempts  to  remove  the  disease 
by  intestinal  resections  are  apt  to  be  followed  by  permanent  fecal  fistulas. 
Even  the  nodular  form  of  tubercular  peritonitis  may  get  well  spontaneously. 

To  summarize  the  treatment  of  the  disease,  it  may  be  said  that  general 
hygienic  measures,  such  as  are  employed  for  tuberculosis  elsewhere,  are  the 
most  important.  If  a  considerable  amount  of  ascites  is  present,  evacuation 
of  the  peritoneal  cavity  by  a  laparotomy  incision  probabty  hastens  a  cure. 
Most  cases  of  adhesive  and  nodular  tubercular  peritonitis  come  to  operation  on 
account  of  the  doubt  in  diagnosis.  When  peritoneal  tuberculosis  is  found  the 
abdominal  wound  is  to  be  closed  without  drainage,  without  further  operation, 
except  when  the  disease  is  confined  to  the  pelvic  organs  without  serious  in- 
volvement of  the  intestines,  or  when  some  condition  is  found  which  demands 
immediate  surgical  intervention. 


General  Inflammatory  Processes 
inflammations  of  the  vulva 

The  vulva  is  relatively  immune  to  infections  on  account  of  the  firm  epithelial 
covering  with  which  it  is  protected.  It  is,  however,  exposed  to  all  sorts  of  inflam- 
matory irritants,  so  that  the  absolute  number  of  affections  to  which  it  is  subject 
is  sufficiently  great. 

Acute  primary  vulvitis  is  a  rare  occurrence  except  in  children,  in  whom 
the  gonococcus  is  the  most  important  exciting  organism.  In  the  adult,  vulvitis 
is  usually  secondary  to  inflammatory  lesions  elsewhere  in  the  genital  tract,  such 
as  may  exist  in  the  endometrium,  endocervix,  or  vagina;  or  it  may  be  the  result 
of  chemical  irritation  from  the  discharges  of  malignant  or  necrotic  new  growths 
above,  or  from  diabetic  urine  or  from  vesical  or  rectal  fistulas,  where  there  is 
maceration  and  destruction  of  the  superficial  epitheUum,  so  as  to  allow  the 
invasion  of  pathogenic  organisms.  Vulvitis  may  also  be  caused  by  trauma  and 
infection  from  masturbation  or  indiscreet  coition,  from  scratching,  or  from 
uncleanliness  and  chafing  during  menstruation. 

The  symptoms  of  vulvitis  are  reddening  and  swelling  of  the  parts,  with  pain 
and  increased  secretion.  Edema  of  the  labia  minora  is  especiafly  marked  and 
may  reach  an  alarming  extent. 

A  special  form  of  vulvitis,  due  usually  to  excessive  scratching  from  pruritus, 
is  a  great  swelhng  of  the  clitoris  and  prepuce,  causing  a  condition  hke  that  of 
acute  phimosis  in  man.  The  secretion  which  bathes  the  vulva  in  vulvitis  differs 
according  to  the  nature  of  the  infection,  the  most  profuse  type  appearing  in 
gonorrhea.  As  the  secretion  dries,  adhesions  and  ulcerations  may  form.  The 
pain  in  the  acute  forms  is  severe  and  distressing,  consisting  of  great  heat  and 
pressure,  coupled  with  burning  on  micturition.  As  the  process  becomes  less 
acute  the  pain  often  gives  way  to  intolerable  itching. 

Gonorrheal  vulvitis,  including  the  vulvovaginitis  of  children,  Bartholinitis, 
the  infection  of  Skene's  glands,  and  the  forms  of  external  gynatresia,  has  been 
treated  under  the  subject  of  Gonorrhea,  to  which  the  reader  is  referred. 

SOFT   CHANCRE 

Soft  chancre,  or  ulcus  molle,  occurs  most  commonly  near  the  frenulum,  but 
may  appear  in  numerous  small  ulcers  over  the  entire  external  genital  apparatus 
and  out  on  the  thighs  and  buttocks.  These  ulcers  are  characterized  by  their 
multiplicity  and  their  great  tendency  to  cause  suppurating  inguinal  buboes. 

224 


GENERAL   INFLAMMATORY   PROCESSES  225 

The  ulcers  are  usually  small,  with  well-defined  edges  and  covered  with  a  thick 
purulent  secretion.  They  are  shallow,  and  are  distinguished  from  syphilitic 
chancre  by  the  absence  of  basal  induration. 

Soft  chancres  are  venereal  in  origin.  They  are  usually  painful,  and  are 
associated  with  a  greater  or  less  amount  of  vulvitis,  which  increases  the  dis- 
comfort. The  buboes  which  are  so  apt  to  follow  are  extremely  painful  and 
usually  suppurate.  The  chancres  are,  as  a  rule,  easily  controlled  by  applying 
to  each  ulcer  some  caustic  solution  like  crude  carboHc  or  chromic  acid,  followed 
by  alcohol.  The  apphcation  of  the  acid  is  momentarily  painful,  but  patients 
are  usually  entirely  willing  to  submit  to  it. 

The  buboes  can  sometimes  be  made  to  subside  and  absorb  by  rest  and  the 
apphcation  of  moist  heat.  If  they  suppurate  it  is  necessary  to  incise  and  evacu- 
ate them,  after  which  the  wound  goes  through  a  process  of  slow  healing.  Patients 
with  buboes  should  be  kept  in  bed,  as  walking  about  greatly  aggravates  the 
condition. 

SKIN  LESIONS 

The  most  common  skin  affection  of  the  vulva  is  that  due  to  chafing,  eczema 
intertrigo.  This  is  seen  especially  in  the  sulcus,  between  the  greater  and  lesser 
lips,  and  in  the  furrows  between  the  vulva  and  the  thighs.  The  skin  is  reddened' 
or  brownish  red  and  may  take  on  a  permanent  discoloration.  The  c6ndition  is 
usually  due  to  uncleanliness,  coupled  with  some  irritating  discharge  froi^n  the 
upper  genital  or  urinary  tract,  and  is  especially  common  in  fat  women  and 
during  hot  weather.  Other  skin  lesions  seen  are  acne,  herpes,  psoriasis, 
molluscum  contagiosum,  etc.  Lichen  sclerosis  is  sometimes  seen.  It  closely 
resembles  kraurosis  in  appearance. 

Seborrhea  is  quite  frequent,  and  is  characterized  by  a  white  secretion,  mostly 
on  the  labia  minora.  The  glands  may  form  cysts  which  sometimes  become  in- 
fected and  suppurate.  The  presence  of  these  small  sebaceous  cysts,  usually 
seen  on  the  labia  majora,  may  be  a  source  of  mental  apprehension  on  the  part 
of  the  patient.     They  often  disappear  spontaneously. 

If  the  cysts  are  giving  pain  or  causing  anxiety,  they  may  be  dissected  out 
under  local  anesthesia.     Otherwise  they  need  no  special  treatment. 

Furunculosis  is  a  disease  that  may  be  the  result  of  uncleanliness,  but  it  some- 
times occurs  periodically  with  menstruation.  It  may  also  appear  as  a  specific 
disease,  usually  near  the  time  of  the  menopause,  in  which  case  it  seems  to  be  the 
result  of  a  local  circulatory  disturbance,  possibly  connected  with  deficiency  of  the 
ovarian  function.  This  latter  type  may  be  much  benefited  by  the  use  of  ovarian 
extract. 

Syphilis.—  The  primary  syphilitic  lesion  of  the  vulva  may  have  exactly  the 
same  appearance  as  that  seen  in  man,  characterized  as  it  is  by  a  smooth,  sharply 
defined  ulcer,  with  hard  indurated  base,  and  a  livid  coloration  of  the  surrounding 
tissue.     In  woman,  however,  there  is  a  much  greater  tendency  to  the  formation  of 

15 


226 


GYNECOLOGY 


multiple  primary  ulcers,  due  chiefly  to  the  fact  that  the  labia  minora  lie  in  close 
proximity  to  each  other,  so  that  the  infection  is  transmitted  from  one  lip  to  the 
other.      For  this  reason  multiple  syphilitic  ulcers  are  often  seen  symmetrically 


Fig.  4tJ. — Condylomata  Acumixata. 

In  this  case  the  excrescences  are  collected  into  discrete  masses.     Usually  the  condylomata  are  more 
widely  scattered  over  the  vulva  and  surrounding  parts. 


located  on  both  labia.  The  initial  lesion  may  be  situated  on  any  part  of  the 
external  genitals,  but  it  is  found  most  commonly  near  the  frenulum,  the  clitoris, 
and  the  inner  surfaces  of  the  labia  minora. 

The  lesions  are  apt  to  be  associated  with  hard  edema  of  the  surroimding  parts 


GENERAL   INFLAMMATORY   PROCESSES 


227 


and  extensive  erosions.     Indolent  buboes  are  felt  in  both  groins,  while  later 
secondary  efflorescent  manifestations  follow. 

Owing  to  the  local  edema,  multiple  ulcerations,  and  erosion  of  the  primary 
affection  syphilis  may  be  confounded  with  elephantiasis,  tuberculosis,  and 
esthiomene.  The  diagnosis  may  be  made  absolute  by  finding  the  Spirochseta 
palUda  and  by  a  positive  Wassermann  reaction. 


Fig.  47. — Condylomata  Acuminata  Vulv^. 
Low  power.     Section  of  a  complete  condsdoma  showing  how  the  papillse  of  the  corium  hyper- 
trophy, growing  outward,  carrying  the  epitheUum  with  them,  giving  the  whole  a  wart-like  appear- 
ance.    The  stroma  beneath  contains  many  dilated  blood-  and  lymph-vessels. 

Condylomata  Acuminata.— These  are  warty  or  papillary  excrescences  that 
appear  on  the  labia  and  surrounding  parts  of  the  external  genitals.  Their  origin 
is  usually  venereal  and  nearly  always  the  result  of  gonorrhea.  They  have  the 
form  of  pointed  papillse,  and  are  termed  "acuminata"  to  distinguish  them  from 
the  broad  condylomata  that  result  from  syphilis.  These  warty  growths  appear 
in  clusters  mostly  on  the  major  and  minor  lips  of  the  vulva.  Other  warts,  either 
.singly  or  in  clusters,  are  sown  about  over  the  neighboring  parts  of  the  buttocks 
-and  thighs.  They  may  even  invade  the  vagina  for  a  short  distance.  Sometimes 
the  clusters  become  very  large.    The  condition  is  frequently  mistaken  for  cancer, 


228 


GYNECOLOGY 


though  to  the  experienced  there  is  no  difficulty  in  making  a  diagnosis.  The 
condylomata  of  themselves  do  not  give  much  trouble  to  the  patient,  but  there 
is  usually  an  associated  leukorrheal  discharge  with  consequent  maceration  and 
soreness  of  the  parts.  The  appearance  of  the  excrescences  may  cause  great 
apprehension  on  the  part  of  the  patient. 


Fig.  48. — Condylomata  Acuminata  Vulvae. 
Higher  power  drawing  of  a  papilla  from  the  previous  section.    The  epithelium  is  thickened,  but 
the  cells  show  no  atypical  growth  and  no  signs  of  invading  the  stroma,  as  they  do  in  carcinoma  of  the 
vulva.     The  stroma  of  the  papilla  contains  several  dilated  blood-vessels  and  is  infiltrated  with  leuko- 
cytes. 


The  growth  of  the  papillse  is  entirely  superficial,  there  being  no  tendency  to 
grow  down  into  the  subcutaneous  tissue.  For  this  reason  the  treatment  is 
very  simple.  It  consists  merely  in  scraping  off  the  papillary  growths  with  a 
sharp  curet.  The  superficial  excoriation  of  the  skin  may  be  painted  with 
iodin  and  the  healing  process  is  very  rapid.  If  the  condylomata  extend  to  the 
softer  parts  of  the  vestibule  and  vaginal  orifice  their  removal  may  be  attended  by 


GENERAL   INFLAMMATORY    PROCESSES 


229 


troublesome  bleeding,  especially  if  the  patient  happens  to  be  pregnant.  If  the 
condylomata  are  at  all  extensive  it  is  best  to  remove  them  under  general  anes- 
thesia. 

ESTHIOMENE 

This  is  a  disease  about  which  we  have  very  little  definite  knowledge.  The 
name  is  adapted  from  the  Greek  word  meaning  to  gnaw  out,  so  that  it  corre- 
sponds practically  to  the  term  "rodent  ulcer."     The  disease  consists  of  an  exten- 


FlG.  49. ESTHIOMENE. 

The  labia  are  hypertrophied,  resembling  somewhat  elephantiasis.     There  is  extensive  ulceration  of 
all  the  parts.     The  ulcerated  areas  have  a  tendency  to  be  symmetric  on  the  two  sides. 

sive  inflammation  and  ulceration  of  the  vulva.  The  parts  are  greatly  swollen 
and  covered  with  superficial  sloughing  areas.  These  areas  are  apt  to  be  at  the 
points  of  contact  of  the  swollen  labia,  so  that  there  is  a  certain  symmetry  in  the 
ulcerations.     The  parts  are  bathed  with  a  foul  purulent  discharge. 

The  origin  of  this  disease  is  obscure.  It  is  seen  mostly  in  prostitutes,  and, 
though  it  is  thought  to  have  some  possible  relationship  to  syphilis,  it  does  not 
yield  at  all  to  syphilitic  treatment.     It  is  regarded  by  some  to  be  the  result  of  a 


230  GYNECOLOGY 

lymph-stasis  in  the  external  genitals,  as  it  sometimes  follows  the  excision  of 
inguinal  buboes.     It  is  often  associated  with  stricture  of  the  rectum. 

Esthiomene  simulates  in  its  appearance  cancer  and  lupus,  from  which  it 
should  always  be  distinguished  by  a  microscopic  examination  of  a  section  of 
tissue. 

There  are  inflammations  of  the  vulva,  especially  in  neglected  gonorrhea 
cases,  where  there  is  much  swelling  of  the  vulva  with  contact  erosions  which 
resemble  esthiomene  rather  closely.  These  conditions,  however,  yield  to  local 
treatment  and  can  in  this  way  be  distinguished. 

The  symptoms  of  esthiomene  are  great  burning  sensation  and  pain  in  the 
external  genitals.     The  patient's  plight  is  distressing  in  the  extreme. 

Local  treatment  of  a  true  esthiomene  ig  almost  hopeless,  and  the  only  means 
of  relief  is  by  a  complete  vulvectomy. 

ELEPHANTIASIS   VULV^ 

Elephantiasis  relates  to  a  coarse  enlargement  of  the  vulva  involving  the  labia 
minora  or  majora,  or  both.  The  outer  appearance  of  these  growths  varies  con- 
siderably, special  names  being  given  to  describe  the  differences  in  surface  struc- 
ture. Thus,  elephantiasis  glabra  relates  to  a  form  which  has  a  smooth  surface; 
elephantiasis  tuberosa,  to  a  form  which  is  covered  with  irregular  nodules;  ele- 
phantiasis condylomatosa,  to  one  covered  with  warty  excrescences  (Gebhard). 
The  hypertrophy  may  become  very  great,  and  the  enlarging  mass  pedunculated, 
tumors  having  been  observed  weighing  as  much  as  30  pounds. 

In  the  course  of  time  severe  ulcerations  may  form,  giving,  an  appearance 
similar  to  that  of  esthiomene.  Histologically,  the  process  consists  of  a  chronic 
indurative  hypertrophy  of  the  subepithelial  connective  tissue,  excepting  in  the 
condylomatous  type,  in  which,  both  microscopically  and  macroscopically,  the 
excrescences  are  almost  exactly  like  those  of  condylomata  acuminata. 

The  etiology  of  elephantiasis  is.  quite  obscure.  The  disease  appears  during 
the  age  of  sexual  maturity..  It  is  much  more  common  in  the  Orient  than  with  us, 
and  for  that  reason  it  is  supposed  that  it  may  be  due  to  some  parasite,  possibly 
bilharzia  (Jaschke). 

Among  some  tribes  of"  the  Hottentots  is  seen  with  considerable  regularity 
an  enormous  lengthening  of  the  labia  minora.  The  term  /'elephantiasis"  is  also 
applied  to  this  condition. 

Elephantiasis  in  many  cases  does  not  at  first  give  symptoms.  The  growth 
may  become  exceedingly  edematous,  causing  lymphorrhea.  If  the  surface  be- 
comes ulcerated  the  condition  may  be  very  painful,  resembling  esthiomene. 
With  the  larger  tumors  coitus  is  entirely  interfered  with. 

The  treatment  of  elephantiasis  is  removal  by  a  partial  or  complete  vulvec- 
tomy, according  to  the  extent  of  the  enlargement. 

A  special  form  of  elephantiasis  is  seen  among  the  Southern  negroes  who  live 


GENERAL   INFLAMMATORY   PROCESSES 


231 


in  the  damp,  sv/ampy  regions  about  the  plantations.  The  disease  has  been 
shown  to  represent  a  condition  of  lymph-stasis,  usually  brought  about  by  the 
Filaria  sanguinis  hominis,  sometimes  by  syphilis  and  other  eruptive  diseases. 
The  fibrous  growth  of  the  tissues  is  not  due  primarily  to  the  lymph-stasis,  but 
to  recurrent  erysipelatous  infections  of  the  affected  part,  each  attack  of  which 


"~^:  ^^r  c\\i  e  s  ■  \  9  <  ST' 


Fig.  50. — Elephantiasis  Vulvae. 
There  is  great  hypertrophy  of  the  labia  majora  with  a  tendency  to  papillary  outgrowth.     On  the 
left  thigh  can  be  seen  several  metastatic  papillary  excrescences  and  a  scar  where  some  of  them  had 
been  removed  at  a  previous  operation.     The  treatment  of  this  case  was  a  complete  vulvectomy.^ 

leaves  the  tissues  more  hypertrophied  (Hill).  The  disease  is  more  common  in 
men,  affecting  the  scrotum  or  lower  extremities.  In  women  it  is  apt  to  involve 
the  external  genitals.  It  is  quite  likely  that  this  form  of  the  disease  is  identical 
with  that  described  among  the  Orientals. 

*  Operation  by  Dr.  F.  A.  Pemberton,  Free  Hospital  for  Women. 


232 


GYNECOLOGY 


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5 '',  {  .  r 


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i 


,^ >  1 ,  ,      .     -       «  •  ,  . 


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rS);^ 


«'.  ? 


'•  ',!  /," 


Fig.  51. — Elephantiasis  of  the  Vulva. 
Low  power.     Microscopically,  this  shows  the  characteristics  of  a  fibroma.     The  thin  layer  of 
stratified  squamous  epithelium  in  which  there  are  few,  poorly  developed,  or  no  papillae,  lying  on  a 
loose  connective-tissue  stroma,  with  a  few  small  round  cells  scattered  through  the  tissue.     Near 
the  center  are  two  dilated  lymph-spaces. 


KRAUROSIS 

The  term  "kraurosis"  is  derived  from  a  Greek  word  meaning  to  shrink.  In  this 
disease  there  is  a  sclerotic  change  in  the  cutis  of  the  vulva.  The  epidermis  be-' 
comes  thin  and  flattened,  and  there  is  an  increase  of  connective  tissue  in  the 
subcutis,  together  with  a  disappearance  of  elastic  fibers  and  pigment.  The  result 
of  this  is  that  the  surface  of  the  vulva  becomes  white  and  parchment-like  and  is 
easily  fissured.  In  the  advanced  stages  the  various  parts  of  the  vulva  become 
obliterated  and  shrink  to  the  consistency  of  leather.  The  process  may  extend 
to  the  anus.  There  is  usually  a  fairly  well-marked  line  of  demarcation  between 
the  diseased  and  healthy  skin. 

The  etiology  of  kraurosis  is  not  always  clear.  There  is  no  doubt  that  it  is 
usually  the  result  of  a  long-continued  irritation  caused  by  discharges  which,  by 
their  chemical  action,  gradually  alter  the  structure  of  the  vulval  cutis.  A 
pruritus  of  the  vulva  from  any  cause  soon  produces  a  white  parchment-hke  ap- 
pearance, which,  if  the  irritating  cause  continues,  in  time  develops  into  a  per- 
manent change.  Some,  however,  regard  the  pathologic  process  of  kraurosis  as 
an  inherent  primary  disease.     This  theory  has  not  been  proved. 


GENEEAL    INFLAMMATORY    PROCESSES 


23^ 


Kraurosis  of  the  vulva  is  related  to  senile  atrophy,  and  reference  should  be 
made  to  that  subject. 

It  not  infrequently  serves  as  a  starting-point  for  cancer  of  the  vulva. 

The  symptoms  of  kraurosis  consist  chiefly  of  intolerable  itching.  Patients 
with  this  disease  suffer  pitifully  and  are  often  driven  to  acts  of  desperation. 


V.jl^rcvMec; 


r-v        <^,v'? 


'i  ■  / 


t 


Fig.  52; — Kraurosis  Vui.v^. 
The  clitoris  and  labia  minora  have  disappeared.     The  vulva  is  white  and  creased.     The  vagina 
is  atrophied  and  stiff  at  the  introitus.     This  was  an  extreme  case  and  was  inoperable  on  account  of 
the  extension  of  the  disease  into  the  orifices  of  the  vagina  and  urethra. 

The  treatment  of  advanced  cases  is  \'Tilvectom3^,  if  the  process  has  not  in- 
volved too  much  vestibule  and  vaginal  introitus. 

Several  cures  from  ovarian  extract  have  been  reported,  one  of  them  by  the 
author.  In  this  condition  ovarian  extract  theoreticall}^  works  benefit  by  its 
power  to  cause  hj^peremia  of  the  external  genitals  and  thus  improve  the  circula- 
tion.   Results  seem  to  bear  out  the  theory.  t 


234 


GYNECOLOGY 


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:'i  ""l^'i 


«  ,''   t 


•"^  ,"  '-^  V"    "-' 


Fig.  53. — Kraurosis  Vulvae. 
Low  power.     On  the  surface  is  a  thick  stratum  corneum,  under  which  is  the  stratum  granulosum, 
much  thinner  than  normal.     The  line  between  this  layer  and  the  corium  is  less  wavy  than  usual,  due 
to  poor  development  of  the  papilliB  of  the  corium.     The  corium  consists  of  dense  connective  tissue 
containing  few  nuclei. 

Leukoplakia  is  a  somewhat  ill-defined  disease,  similar  to  kraurosis,  but 
differing  from  it  in  that  it  appears  in  the  form  of  whitish  plaques  scattered 
over  the  vulvar  area  rather  than  a  general  atrophic  process  involving  the  entire 
vulva.  The  histologic  changes  in  leukoplakia  are  more  superficial  than  those  of 
kraurosis,  being  located  in  the  epidermis.  In  kraurosis  they  are  situated  in  the 
dermis  (Taussig) .    Leukoplakia  may  be  the  seat  of  a  primary  cancer  of  the  vulva. 

Paget's  disease  occurs  rarely  in  the  vulva  and  may  serve  as  a  point  of  origin 
for  cancer.  It  is  characterized  by  local  irritation,  the  formation  of  white  blis- 
ters, thickening  of  the  parts,  and  ultimate  ulceration  and  bleeding.  The  disease 
in  relation  to  the  vulva  has  been  described  by  Dubreullh.  Taussig  has  recently 
called  attention  to  the  part  it  may  play  in  the  etiology  of  cancer  of  the  vulva. 

PRURITUS 

Pruritus  means  itching  and,  strictly  speaking,  describes  a  symptom  rather 
than  a  disease.  Common  usage,  however,  treats  pruritus  as  a  disease,  and  we 
shall,  therefore,  use  the  term  in  that  sense. 

Pruritus  is  closely  related  to  kraurosis,  which  it  always  precedes  as  an  earlier 


GENERAL    INFLAMMATORY    PROCESSES  235 

stage.  It  is  characterized  at  first  by  a  reddening  and  thickening  of  the  vulval 
cuticle  associated  with  intense  burning  and  itching.  The  surface  gradual^  be- 
comes pale  and  parchment-like,  with  a  tendency  to  cracks  and  j&ssures.  As  the 
process  continues  it  merges  into  the  condition  of  kraurosis.  There  is  no  marked 
chviding  line  between  pruritus  and  kraurosis,  and  they  must  be  regarded  as 
different  stages  of  the  same  pathologic  process. 

Pruritus,  like  kraurosis,  is  usually  secondary  to  some  irritating  discharge 
that  produces  the  skin  changes  by  chemical  action.  It  is,  however,  considered 
by  some  to  constitute  sometimes  a  primary  disease,  consisting  of  an  essential 
fibrosis  or  sclerosis  of  the  epidermis.  In  other  words,  the  pathologic  changes  are 
identical  with  those  of  kraurosis.  It  would  be  better,  therefore,  to  apply  the 
term  kraurosis  to  the  changes  in  the  tissues  and  the  term  pruritus  to  the  symp- 
toms resulting  therefrom. 

Pruritus  of  the  vulva  is  usually  the  result  of  a  discharge  from  some  part  of 
the  upper  genital  or  uninary  tract,  and  when  a  patient  suffering  with  this  symptom 
presents  herself  the  most  careful  examination  should  be  made  to  discover  the  cause. 

The  causes  of  pruritus  are  numerous,  a  diabetic  urine  being  foremost  among 
them.  Pruritus  in  this  case  is  due  to  chemical  irritation.  If  the  sugar  in  the 
urine  is  sufficiently  reduced  the  itching  ceases.  Patients  suffering  from  pruritus 
should  always  have  the  urine  examined  for  sugar  at  once  as  a  routine  measure. 
Leukorrheal  discharges  from  various  sources  sometimes  produce  pruritus. 
Examples  of  this  are  the  irritating  discharges  from  cancer  of  the  uterus,  necrotic 
polyps,  sloughing  fibroids,  pessaries,  cervicitis,  and  endocervicitis.  A  very  im- 
portant cause  is  partial  atresia  of  the  vagina  or  cervix,  in  which  the  normal  men- 
struation and  mucous  secretion,  not  having  proper  drainage,  become  infected  or 
chemically  changed,  and  thus  serve  as  severe  irritants  to  the  external  genitals. 

In  women  near  or  past  the  menopause  senile  atrophy  is  a  very  common  etio- 
logic  factor  in  producing  pruritus.  Senile  atrophy  of  itself  brings  about  a  change 
in  the  vulva  that  is  somewhat  similar  to  that  caused  by  long-continued  pruritus — 
i.  e.,  a  thinning  and  flattening  of  the  epidermis,  coupled  with  an  increase  of  con- 
nective tissue  and  loss  of  elastic  fibers.  By  this  change  the  vulva  is  more  sus- 
ceptible to  chemical  irritation.  Senile  atrophy,  moreover,  is  the  means  of  cre- 
ating abnormal  secretions.  It  often  produces  an  excessive  desquamation  of  the 
vaginal  epithehum  which  results  in  an  irritating  vaginitis.  Senile  atrophy,  by 
contracting  the  vaginal  outlet  or  by  partially  or  intermittently  sealing  the  cer- 
vical OS,  may  prevent  proper  drainage  of  the  vaginal  or  uterine  secretions  and 
thus  render  them  chemically  irritating.  Other  causes  of  pruritus  are  furunculosis 
and  seborrhea  of  the  labia  majora. 

The  treatment  of  pruritus  is  primarily  to  find  the  cause  of  the  irritation,  and 
this  can  generally  be  done.  Diabetes  and  the  grosser  lesions  mentioned  above 
are  readily  detected  and  treated  by  the  accepted  methods.  The  importance  that 
senile  atrophy  plays  is  not  sufficientlj^  well  recognized,  and  there  is  little  doubt 
that  many  of  the  cases  in  which  the  disease  is  thought  to  be  primary  fall  into  this 
class.     The  principle  to  be  observed  in  the  treatment  is  to  secure  proper  drainage 


236  GYNECOLOGY 

of  the  vaginai  and  uterine  secretions.  A  valve-like  perineal  outlet  must  be  treated 
by  a  plastic  operation  which  will  secure  a  funnel-shaped  introitus.  Obstructing 
atresia  of  the  vagina  must  be  operated  on  in  the  manner  recommended  for  that 
condition. 

Atresia  of  the  cervix  is  treated  by  creating  an  artificial  laceration  so  that  the 
lips  will  pout  outward.  If  the  atresia  of  the  cervix  is  too  high  for  the  perform- 
ance of  a  plastic  operation,  dilatation  is  first  performed,  and  if  atresia  recurs, 
as  it  sometimes  does,  it  may  be  necessary  to  remove  the  uterus  and  cervical  canal 
by  the  operation  suggested  on  page  724. 

If  the  pruritus  is  due  to  a  senile  vaginitis  where  there  is  no  obstruction, 
iodin  applications  to  the  vagina  usually  control  the  discharge. 

Palhative  measures  usually  give  only  temporary  or  fleeting  relief.  These 
consist  usually  of  cooling  lotions  or  salves,  in  which  carbohc  acid,  alcohol,  hama- 
mehs,  and  menthol  are  the  most  commonly  used  ingredients.  Pure  ichthyol 
smeared  on  the  itching  parts  sometimes  gives  rehef.  Various  suppositories 
of  codein,  cocain,  etc.,  are  sometimes  prescribed.  Radium  and  the^-ray  some- 
times give  great  relief. 

If  the  condition  has  continued  for  so  long  that  a  permanent  change  has 
taken  place  in  the  tissues,  the  process  is  to  be  classified  as  kraurosis,  and  is  then 
essentially  a  disease.  If  this  stage  is  reached  the  removal  of  the  original  cause 
may  not  reheve  the  symptoms.  Vulvectomy  may  then  be  necessary.  Before 
performing  this  operation  it  is  well  to  try  a  course  of  ovarian  extract,  5-gr.  cap- 
sules four  times  daily.  The  author  has  had  success  with  ovarian  extract  in  a 
case  of  furunculosis  which  caused  pruritus. 

VAGINITIS    (OR  COLPITIS) 

When  one  considers  the  amount  of  trauma  that  the  vagina  is  subjected  to 
from  coitus,  childbirth,  medical  examinations,  instrumentation,  introduction  of 
foreign  bodies,  etc.,  and  its  exposure  to  infectious  organisms  that  are  introduced 
by  coitus  or  manipulation,  or  that  may  be  transmitted  from  the  neighboring 
outlets  of  the  bladder  and  rectum,  it  is  a  matter  of  wonder  that  inflammations 
play  so  unimportant  a  part.  The  comparative  immunity  of  the  vagina  to  infec- 
tion is  due  partly  to  the  protecting  squamous  epithelium  that  fines  its  surface 
and  partly  to  its  normally  acid  secretion,  which  is  inimical  to  the  growth  of 
many  microorganisms.  Thus,  we  have  already  seen  that  the  vagina,  though 
susceptible  to  various  infections,  especially  that  of  the  gonococcus,  in  the  early 
years  of  life,  is,  during  maturity,  rarely  the  seat  of  primary  inflammations.  Ex- 
cepting in  childhood,  inflammatory  processes  in  the  vagina  presuppose  some 
mechanical  or  chemical  injury  to  the  surface  epithelium  that  allows  invasion  of 
pathogenic  germs.  For  example,  the  vaginitis  seen  in  gonorrhea  of  adults  is  the 
result,  first,  of  maceration  of  the  vaginal  epithelium  by  the  catarrhal  secretion 
from  a  gonorrheal  endocervicitis,  and,  secondarily,  of  an  infection  by  other 
organisms  of  the  damaged  surface.     Furthermore,  certain  circulatory  changes, 


GENERAL    INFLAMMATORY    PROCESSES  237 

which  cause  a  local  hyperemia  of  the  vaginal  blood-vessels,  favor  inflammatory 
processes  in  the  vagina.  Thus,  infections  are  more  common  during  pregnancy 
or  in  conditions  attended  with  passive  congestion,  such  as  are  seen  in  cardio- 
renal  and  liver  diseases  or  with  constant  masturbation. 

Vaginitis  may  occur  as  an  acute  diffuse  inflammatory  process  in  the  vaginal 
wall.  The  diffuse  form,  as  a  rule,  occurs  only  in  the  young,  and  is  especially  ex- 
emplified in  the  gonorrheal  vaginitis  of  children,  though  it  sometimes  is  seen  in 
the  adult.  Here  the  entire  vaginal  membrane  is  red  and  swollen,  easily  bleed- 
ing, and  profusely  bathed  in  the  inflammatory  secretion. 

In  the  localized  chronic  form  of  vaginitis  the  process  is  confined  to  certain 
areas  of  the  vagina  whicji  gives  a  spotted  or  mottled  appearance  to  the  surface. 
This  type  is  especially  marked  at  the  time  of  senile  atrophy,  when  the  reddened, 
easily  bleeding  spots  of  inflammation  show  in  clear  contrast  to  the  smooth  pale 
atrophic  surface  of  the  normal  vaginal  mucous  membrane.  The  reddened  spots 
vary  from  a  pin-point  to  a  centimeter  or  two  in  size. 

Vaginitis  in  all  stages  may  be  attended  with  loss  of  surface  epithelium  and 
ulceration,  with  possible  later  permanent  adhesions  of  opposing  vaginal  surfaces. 
In  this  way  are  formed  most  of  the  partial  or  complete  atresias  of  the  vagina. 

All  forms  of  vaginitis  are  attended  with  a  leukorrheal  discharge  whicli 
varies  greatly  in  amount  and  consistency.  In  the  acute  diffuse  type  of  vaginitis 
the  dischage  is  purulent  and  creamy  and  very  profuse.  In  the  milder  forms  of 
chronic  vaginitis  it  has  more  of  a  turbid,  serous  character,  while  in  the  senile 
type  it  is  white  and  milky,  due  to  the  great  amount  of  desquamated  epithehum 
contained  in  it.  If  there  is  bleeding  from  the  vaginal  surface  the  dischage  is 
brownish  or  even  red. 

Causes  of  Vaginitis. — The  two  most  common  causes  of  vaginitis  are  gonor- 
rhea and  senile  atrophy  (g.  v.).  SyphiHs  and  tuberculosis  of  the  vagina  ar-e 
rare  causes. 

Long-standing  endocervical  catarrh  may  keep  up  an  intractable  vaginitis,  as 
may  also  a  chronic  endometritis,  masturbation,  and  excessive  coitus. 

A  very  frequent  cause  of  vaginitis  is  neglected  pessaries  or  tampons.  Pes- 
saries that  are  ill-fitting,  or  that  are  retained  for  long  periods  without  proper 
cleanliness,  ulcerate  the  vaginal  epithelial  surface,  and  may  even  be  buried  in  the 
wall  by  a  new  growth  of  epithelium.  Other  foreign  bodies  kept  in  the  vagina 
may  produce  ulceration  and  chronic  inflammation. 

Prolapse  of  the  vagina  and  uterus  causes  by  exposure  a  thickening  and  cornif- 
ication  of  the  vaginal  mucous  membrane.  If  the  prolapse  is  extreme  and  the 
surface  is  subjected  to  constant  trauma,  the  most  prominent  parts  become  seats 
of  decubitus  or  pressure  ulcers,  which,  if  not  properly  treated,  become  infected 
and  covered  with  a  slimy  secretion. 

Vaginitis  may  rarely  attend  infectious  diseases  like  measles,  scarlet  fever, 
typhoid,  small-pox,  diphtheria,  and  cholera.  In  these  cases  the  vaginitis  is  of 
tlie  diffuse  type,  the  canal  being  covered  with  a  croupous  membrane.  Ulcera- 
tion and  atresia  may  be  the  end-result  of  such  inflammations. 


238  GYNECOLOGY 

Circumscribed  vaginitis  is  occasionally  seen  with  puerperal  fever,  and  may 
be  followed  by  obstructing  adhesions  of  the  vaginal  wall,  usually  in  the  upper 
part  of  the  vagina  near  the  portio. 

Partial  atresia  of  the  vagina  or  cervix  is  usually  attended  with  vaginitis  on 
account  of  the  damaging  influence  on  the  surface  epithelium  of  the  stagnant  and 
chemically  changed  secretions. 

Among  children  an  acute  vulvovaginitis  simulating  that  caused  by  gonorrhea 
may  be  set  up  by  wandering  thread-worms  from  the  rectum,  chiefly  the  Oxyuris 
vermicularis.  Cases  are  on  record  in  which  this  parasite  has  traveled  from  the 
vagina  through  the  uterus  and  tubes  to  the  peritoneal  cayity  with  serious 
results. 

Other  vaginal  parasites  are  the  Amoeba  urogenitaHs,  a  protozoan  which  in- 
vades also  the  bladder,  causing  hematuria,  and  the  Trichomonas  vaginahs,  which 
flourishes  in  the  acid  secretion  of  the  vagina.  Still  another  parasite,  Distoma 
haematobium  (formerly  called  Bilharzia  hsematobia) ,  is  found  in  a  large  percent- 
age of  Egyptian  women.  This  organism  infests  chiefly  the  urinary  tract,  but 
in  some  cases  it  propagates  on  the  vulval  epidermis,  where  it  causes  excrescences 
very  like  condylomata  acuminata.  It  sometimes  invades  the  vaginal  mucous 
membrane,  in  which  it  produces  a  thick,  leathery  infiltration.  On  the  cervix  it 
causes  papillary  outgrowths  of  a  carcinomatous  appearance  (Fiith). 

Various  forms  of  fungi  produce  an  inflammation  of  the  vagina  which  macro- 
scopically  exhibits  white  plaques  on  a  diffusely  reddened  mucous  membrane. 
The  growth  of  fungi  in  the  vagina  is  especially  favored  by  a  diabetic  urine. 

Symptoms. — In  the  milder  forms  of  chronic  vaginitis  there  may  be  no  definite 
subjective  symptoms  unless  the  discharge  is  chemically  irritating,  in  which  case 
there  is  burning  and  itching  of  the  external  genitals  with  frequency  or  pain  on 
micturition.  If  the  vaginitis  is  more  severe  or  acute,  there  is  a  sense  of  burning 
and  weight  in  the  vagina,  the  sensations  being  usually  referred  to  the  pelvis,  so 
that  the  patient  often  thinks  that  she  is  suffering  from  a  falling  of  the  womb.  The 
leukorrhea  is  always  noticed  by  the  patient,  and  it  is  this  manifestation  that  usu- 
ally brings  her  to  consult  her  physician. 

Treatment. — The  first  step  in  the  treatment  of  vaginitis  is  to  discover  and 
direct  attention  to  the  primary  source  of  the  irritant  that  is  maintaining  the 
vaginal  inflammation.  This  can  usually  be  done,  for,  as  we  have  seen  with  the 
exception  of  the  somewhat  uncommon  specific  local  infections  of  gonorrhea,  tuber- 
culosis, and  syphihs,  the  initial  trouble  lies  elsewhere  than  in  the  vagina.  Unfor- 
tunately, the  vaginitis  does  not  always  disappear  after  the  instigating  cause 
has  been  removed.  The  local  treatment  of  the  vagina  itself  consists  chiefly  in  the 
use  of  douches  (salt  solution,  boric  acid,  alum,  sodium  bicarbonate,  permanganate 
of  potash,  irrigol,  the  silver  preparations,  etc.)  and  certain  local  apphcations> 
of  which  tincture  of  iodin  is  by  far  the  most  valuable.  In  some  cases  tampons 
soaked  in  glycerin  and  ichthyol  are  useful  if  employed  in  connection  with 
douches  and  iodin.  Vaginal  suppositories  of  ichthyol  may  be  used  in  the  same 
way,  but  are  not  very  efficacious.     Senile  vaginitis,  if  not  the  result  of  obstruc- 


GENERAL    INFLAMMATORY    PROCESSES 


239 


tion  of  secretions  is  best  controlled  by  painting  the  vagina  with  iodin  without 
the  use  of  tampons. 

The  progress  of  vaginitis,  as  far  as  complete  cure  is  concerned,  is  often  un- 
favorable. It  is  best  to  treat  the  intractable  cases  in  a  hospital,  where  com- 
petent nursing  and  systematic  treatment  will  often  accomphsh  in  a  short  time 
results  that  weeks  of  office  or  out-patient  treatment  fail  to  secure. 

Vaginitis  Emphysematosa. — This  is  a  special  disease  that  occurs  ahnost 
exclusively  during  pregnancy  and  disappears  after  delivery.  There  is  little  or 
no  discharge  resultant  from  it,  and  few  synaptoms,  so  that  it  often  passes  un- 
noticed.    It  is  characterized  by  small  blebs  of  the  vaginal  surface,  which  some- 


FiG.  54. — Chronic  Endocervicitis. 
Low  power.  Near  the  top  are  five  cervical  glands  in  cross-section,  lined  by  the  typical  cylindric 
epithelium.  The  tissue  around  them  is  infiltrated  with  leukocytes.  To  the  right  of  these  glands  and 
in  the  lower  part  of  the  section  are  areas  of  squamous  epithelium  which  has  grown  down  into  the 
glands,  filling  them.  These  areas  are  typical  stratified  squamous  epithelium  and  must  be  differenti- 
ated from  carcinoma. 


times  reach  the  dimensions  of  small  cysts.  Upon  incising  them  a  small  amount  of 
gas  escapes. 

The  etiology  of  this  condition  has  not  been  clearly  proved,  but  it  is  sup- 
posed, on  fairly  good  evidence,  that  it  is  the  result  of  some  gas-forming  bacillus. 

The  clinical  importance  of  this  disease  is  insignificant > 


240 


GYNECOLOGY 


Garrulitas  Vaginae. — ^^This  is  a  condition  which  is  characterized  by  the  audible 
escape  of  gas  from  the  vagina  following  certain  quick  changes  of  bodily  position, 
and  which  has  been  thought  to  be  the  result  of  gas-forming  bacteria  in  the 
vagina.  It  is  more  likely  entirely  mechanical  in  origin,  the  result  of  incomplete 
valvular  closure  of  the  introitus  (Jaschke). 

Paravaginitis  (paracolpitis)  relates  to  an  acute  phlegmonous  inflammation 
of  the  tissue  surrounding  the  vagina.  It  is  the  result  of  deep  infection  following 
some  serious  lesion  of  the  vagina,  such  as  may  occur  from  instrumentation  at 


(& 


m\ 


Fig.  55. — Chronic  Endocervicitis. 
High  power.     On  the  left  is  a  cervical  gland  the  epithelium  of  which  is  being  invaded  by  lympho- 
cytes.    The  rest  of  the  drawing  shows  the  stroma  of  the  cervix  infiltrated  with  leukocytes,  mostly  of 
the  mononuclear  variety.     This  infiltration  occurs  around  the  glands,  as  would  be  expected,  because 
bacteria  gain  entrance  through  them. 


childbirth,  violent  coition,  attempts  at  criminal  abortion,  etc.  Such  an  inflam- 
mation may  become  of  the  gravest  import  by  extending  to  the  pelvis  and  causing 
a  fatal  septic  peritonitis.  The  infection  may  remain  localized  and  has,  during 
healing,  an  especial  tendency  to  cause  atresia  of  the  vagina. 

Treatment  is  carried  out  by  hot  or  cold  antiseptic  douches,  with  application 
of  rubber  or  glass  plugs  during  convalescence  to  prevent  the  formation  of  vaginal 
adhesions.     Localized  abscesses  require  incision  and  drainage. 


GENERAL   INFLAMMATORY   PROCESSES 


241 


CERVICITIS    AND    ENDOCERVICITIS 

Non-specific  infections  of  the  cervix  and  cervical  mucous  membrane  are,  in 
the  majority  of  cases,  due  to  lacerations  that  result  in  erosion  or  ectropion.  This 
subject  is  treated  in  the  section  on  Lacerations  from  Childbirth. 

Erosion  of  the  cervix  is  occasionally  seen  in  virgins,  and  is  accountable  for 
the  persistent  leukorrhea  from  which  they  sometimes  suffer.     The  cause  of  these 


Fig.  56. — Chronic  Endocervicitis.     High  Power  of  the  Cervical  Glands. 
The  glands  are  dilated  and  were  filled  with  mucus  containing  desquamated    epithelial   cells, 
round  cells,  and  bacteria,  but  have  become  emptied  in  preparing  the  section.     At  places,  as  in  the 
upper  left  corner,  the  epithelium  is  absent.     The  stroma  between  the  glands  is  edematous  and  infil- 
trated with  round  cells. 


erosions  is  not  definitely  known.  It  is  probable,  however,  that  it  is  due  to  ab- 
normal mechanical  irritation,  for  the  condition  is  most  frequently  seen  when 
there  is  a  malposition  of  the  cervix,  so  that  it  impinges  on  the  anterior  vaginal 
wall,  or  when  the  cervix  is  disproportionately  long,  so  that  it  is  in  too  close  con- 
tact with  the  posterior  wall. 

In  cases  of  genital  atrophy  and  vaginitis  the  cervix  may  take  part  in  the 

16 


242  GYNECOLOGY 

inflammation  and  result  in  plastic  adhesions,  causing  atresia  with  hydro-  or  pyo- 
metra  (g.  v.). 

The  symptoms  of  endocervicitis  and  cervicitis  consist  of  leukorrheal  dis- 
charges.     The  treatment  is  either  local  apphcation  of   iodin  or  an  operation 


5f        #^ 


Viif\ 


^^'-'  ^ 


/  a  /  ^\^^^s'm  ^4-^ 


Fig.  57.  — Chronic  Cervicitis.  Pseudohealing  of  an  Erosion. 
High  power.  The  left  half  of  the  picture  shows  the  duct  of  a  gland  occluded  by  the  stratified 
squamous  epithelium  of  the  cervix  which  has  grown  over  and  down  into  it.  On  the  right  is  a  duct 
down  into  which  the  squamous  epithelium  is  growing  along  the  wall,  but  which  has  not  become  oc- 
cluded. Below  the  squamous  epithelium  is  seen  the  normal  cylindric  epithelium  which  lines  the 
glands  of  the  cervix. 

which  will  restore  the  cervix  to  its  normal  contour  and  position.  Very  intrac- 
table cases  can  be  cured  by  Schroder's  operation  of  complete  removal  of  the 
cervical  mucosa  (g.  v.). 

ENDOMETRITIS 

The  mucous  membrane  of  the  body  of  the  uterus,  or  endometrium,  is  a 
tissue  which  has  been  greatly  misunderstood.     It  is,  in  reality,  a  comparatively 


GENERAL   INFLAMMATORY   PROCESSES  243 

inoffensive    tissue,    and   very   little    responsible   for    the   many   ills   formerly 
ascribed  to  it. 

The  destiny  of  the  endometrium  is  primarily  to  be  the  soil  for  the  implanta- 
tion of  the  impregnated  ovum.  It  is  doubtless  for  this  reason  that  nature  pro- 
vided that  it  be  comparatively  immune  to  the  infections  and  malignant  growths 
common  to  other  membranes.  Thus,  we  have  seen  that,  except  in  the  puer- 
peral state,  it  is  protected  against  practically  all  infectious  organisms  except 
the  tubercle  bacillus  and  the  gonococcus.  Even  tuberculosis  of  the  endometrium 
is  quite  uncommon,  while  the  gonococcus,  in  its  passage  from  the  endocervix  to 
the  tubes,  resides  only  for  a  short  period  on  the  endometrial  surface  and  rarely 
leaves  any  permanent  trace  of  its  sojourn. 

During  the  puerperium,  however,  when  a  part  of  its  surface  is  lacerated  and 
denuded  by  the  separation  of  the  placenta,  the  remaining  part  swollen  to  a 
vulnerable  decidua,  and  the  protective  barrier  of  the  internal  os  stretched  widely 
open,  the  endometrium  is  exposed  and  susceptible  to  the  attack  of  infectious 
organisms.  It  is  at  this  time  that  the  more  serious  inflammations  of  the  endo- 
metrium occur,  and  from  these  attacks  the  chronic  inflammatory  changes  more 
commonly  date  their  origin. 

.  The  subject  of  endometritis  is  at  present  in  a  considerable  state  of  confusion 
due  to  the  fact  that  the  terminology  which  is  in  common  use  has  been  handed 
down  from  a  time  when  the  pathology  of  the  endometrium  was  little  understood. 
In  some  of  the  older  books  no  clear  distinction  was  made  between  the  mucous 
membrane  of  the  body  and  that  of  the  cervix,  so  that  diseases  were  ascribed  to 
the  endometrium  which,  in  reality,  are  locahzed  in  the  endocervix.  In  fact,  the 
endometrium  was  supposed  to  be  affected  in  most  forms  of  pelvic  disease, 
and  this  led  to  a  great  deal  of  local  treatment  and  cureting -that  was  not  only 
not  necessary,  but  often  harmful.  Thus,  patients  with  pelvic  inflammation, 
misplacements,  leukorrhea,  and  irregular  menses  were  apt  to  receive  vigorous 
treatment  of  the  endometrium  as  a  routine  measure.  The  term  ''endometritis" 
was  loosely  applied  to  all  the  changes  in  the  uterine  canal,  and  it  was  supposed 
that  the  effects  arising  from  this  disease  were  serious  and  far  reaching.  More 
recent  studies  have  entirely  changed  this  erroneous  conception  of  the  endome- 
trium, and  it  is  now  known  that  this  membrane  plays  only  a  comparatively 
small  part  in  gynecologic  disease. 

In  the  first  place,  we  must  limit  the  word  ''endometritis"  only  to  such  condi- 
tions as  imply  a  true  inflammatory  process  in  the  endometrium.  This  relates 
to  infections  by  pathogenic  organisms  and  to  chronic  changes  that  result  from 
these  infections.  The  circulatory  changes,  both  physiologic  and  pathologic, 
must  be  given  appropriate  names,  and  not  be  included  as  formerly  under  the 
misleading  title  of  "endometritis." 

No  entirely  satisfactory  classification  of  the  diseases  of  the  endometrium  has 
yet  been  made,  and  we  must  be  content  to  try  and  simplify  the  subject  as  much 
as  possible. 


244 


GYNECOLOGY 


The  changes  of  the  endometrium,  formerly  included  under  the  general  term 
"endometritis,"  may  be  divided  into  three  types:  (1)  Infectious  endometritis,  the 
result  of  microbic  invasion;  (2)  chronic  interstitial  endometritis,  resulting  from  a 
previous  infectious  attack,  and  (3)  gland  hypertrophy,  resulting  from  circulatory 
changes. 

INFECTIOUS    ENDOMETRITIS 

Serious  infections  of  the  endometrium  occur  most  commonly  as  a  result  of 
puerperal  sepsis.     The  endometrium  is  at  this  time  in  a  peculiarly  exposed  con- 


FiG.  58. — Acute  Endometritis. 
High  power.     Parts  of  two  glands  are  seen.     The  stroma  between  them  is  edematous,  the  cells 
are  swollen,  the  nuclei  large,  and  it  is  infiltrated  with  leukocytes.     In  the  upper  part  of  the  drawing 
is  a  mass  of  exudate  in  the  lumen  of  glands  consisting  of  leukocytes,  epithelial  cells,  and  mucus. 


dition  owing  to  the  denudation  resulting  from  the  separation  of  the  placenta, 
the  patency  of  the  cervix,  and  the  general  vascularity  of  the  parts.  The  organ- 
isms which  most  commonly  attack  the  endometrium  at  this  time  are  the  strepto- 
coccus, the  staphylococcus,  and  the  latent  gonococcus.  The  inflammatory  proc- 
ess may  remain  localized  in  the  endometrium  or  it  may  extend  deeply  into  the 


GENERAL   INFLAMMATORY   PROCESSES 


245 


muscular  wall  of  the  uterus.  It  may  spread  to  the  pelvic  cavity  and  cause  a 
peritonitis  either  by  extension  through  the  tubes  or  through  the  l>Tnph-spaces 
of  the  uterine  wall  to  the  parametrium. 

Infectious  endometritis  may  result  from  gonorrhea.  The  most  serious  forms 
of  gonorrheal  endometritis  are  caused  by  the  lighting  up  by  the  puerperium  of  a 
latent  gonorrhea.  Under  these  circumstances  the  endometrium  does  not 
possess  its  normal  immunity  to  the  gonococcus,  and  the  infection  may  be  severe 
and  dangerous.     This  invasion  of  the  gonococcus  accounts  for  many  cases  of 


Fig.  59 — Chronic  Interstitial  Endometritis. 
High  power.     This  section  is  stained  to  show  the  plasma  cells  which  are  found  in  chronic  in- 
flammatory conditions,  and  are  important  in  this  special  disease  because  their  presence  in  large 
numbers  makes  the  diagnosis  more  certain.     They  are  characterized   by  their  large  size   and   the 
excentrically  placed  nucleus. 


puerperal  sepsis,  the  later  results  of  which  are  manifested  by  chronic  inflam- 
mation and  one-child  sterility. 

Outside  of  the  puerperal  state  infectious  endometritis  is  astonishingh'  un- 
common. Routine  curetings,  removed  for  diagnosis  in  vaginal  operations,  and 
the  cases  of  pehdc  inflammation  requiring  hysterectomy  supply  ample  material 
for  the  microscopic  study  of  the  endometrium.  The  percentage  of  true  infectious 
endometritis  is  very  small,  while  evidences  of  acute  purulent  inflammation  are 
rare. 


246 


GYNECOLOGY 


Treatment. — Acute  infectious  endometritis,  outside  of  puerperal  sepsis,  is 
not  a  disease  requiring  specific  treatment  except  in  unusual  instances.  It 
must  be  always  remembered  that  the  use  of  the  curet  in  any  septic  condition 
of  the  endometrium  is  dangerous,  for  it  opens  new  avenues  for  the  spread  of  the 
inflammatory  process  to  the  pelvic  peritoneum.  The  endometrium  may  be 
infected  by  the  passage,  of  unclean  instruments  past  the  internal  os.     It  is  also 


Fig.  60. — Interstitial  Endometritis. 
High  power.     This   illustrates  the   diffuse   infiltration  of  the   stroma  with   small  round  cells 
which  can  be  seen  scattered  throughout  the  section.     The  stroma  cells  are  swollen  and  there  is 
some  edema. 


possible  to  cause  infection  during  a  cureting  operation  by  carrying  organisms 
from  an  infected  endocervix  and  implanting  them  on  the  endometrium.  This  is 
another  of  the  dangers  in  using  the  curet. 

Tuberculosis  of  the  endometrium  comes  under  the  heading  of  Infectious 
Endometritis.     It  is  discussed  on  page  244. 

Senile  atrophy  sometimes  predisposes  the  endocervix  and  endometrium  to 


GENERAL   INFLAMMATORY   PROCESSES 


247 


infection  which  produces  plastic  adhesions  and  partial  or  complete  atresia. 
The  result  may  be  the  backing  up  of  pus  in  the  uterine  canal,  so-called  pyometra 
(q.  v.). 

CHRONIC   INTERSTITIAL   ENDOMETRITIS 

This  is  a  condition  the  pathology  and  symptomatology  of  which  are  not 
sufficiently  understood.  It  consists  in  a  structural  change  in  the  endometrium 
which  is  evidently  the  result  of  some  previous  active  infectious  process.     In  our 


^>  *,>Sf  ^V^^^  <»n 


Fig.  61. — Chronic  Interstitial  Endometritis. 
Low  power.     This  section  shows  the  dilatation  of  the  glands  Which  is  sometimes  found  in  this 
condition.     The  epithelial  cells  are  low  and  inactive,  the  glands  are  usually  circular,  while  in  pre- 
menstrual dilatation  they  are  irregular  in  outline.     The  stroma  is  denser  than  normal  and  collections 
of  small  round  cells  can  be  seen. 

series  of  cases  there  is  a  noticeably  large  percentage  of  abortions  in  the  patients' 
histories,  while  many  of  the  cases  had  associated  pelvic  inflammatory  disease. 

The  endometrium  is  thickened  to  a  greater  or  less  extent.  Under  the  micro- 
scope the  thickening  is  seen  to  be  due  to  an  increase  of  the  stroma,  in  which  there 
is  a  marked  infiltration  of  small  round  cells.  This  condition  is  probably  one  of 
the  factors  which  sometimes  cause  abnormal  bleeding  in  association  with  pelvic 
inflammation.     Chronic  endometritis  cannot  be  easily  diagnosed,  nor  can  it 


248 


GYNECOLOGY 


often  be  satisfactorily  treated  as  a  disease  by  itself,  for  local  applications  to  the 
endometrium  are  not  feasible,  while  a  cureting  may  light  up  into  dangerous  ac- 
tivity a  latent  pelvic  inflammation. 

There  are  various  grades  of  chronic  inflammation  of  the  endometrium  which 
are  of  interest  microscopically,  but  which  cannot  be  distinguished  by  clinical 
symptoms. 

Driessen  has  described  a  special  form  of  endometritis  which  he  calls  "postmenstrual  necro- 
biotic  endometritis,"  the  cUnical  symptom  of  which  is  profuse  and  protracted  menorrhagia. 


Fig.  62. — Chronic  Interstitial  Endometritis. 
High  power.     Parts  of  two  glands  are  seen,  the  epithelium  of  which  is  infiltrated  with  round 
cells.     The  stroma  is  edematous,  infiltrated  with  round  cells,  and  has  an  increased  amount  of  fibrous 
tissue. 


The  endometrium  in  these  cases  is  found  to  show  necrosis,  hyahne  degeneration,  infiltration  with 
multinuclear  leukocytes,  dilatation  of  the  vessels,  cystic  dilatation  of  the  glands,  proliferation 
of  the  epithelium,  and  deficient  glycogen.  He  also  finds  signs  of  incomplete  regeneration  of  the 
uterine  mucosa,  such  as  is  seen  in  endometritis  following  abortion. 

Driessen  explains  this  condition  on  the  ground  that  on  account  of  some  irregularity  in  ovula- 
tion and  menstruation  the  mucosa  is  not  cast  off  as  it  should  be  normally,  and  that  the  portions 
of  the  mucous  membrane  remaining  and  disintegrating  in  the  canal  prevent  a  normal  regenera- 
tion of  the  endometrium  with  consequent  bleeding,  as  do  the  remnants  of  an  abortion  or  the 
decidua.     Cureting  may  cure  or  only  temporarily  relieve  the  condition. 


GENERAL   INFLAMMATORY   PROCESSES 


249 


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Fig.  63. — Chronic  Interstitial  Endometritis. 
High  power.     The  stroma  cells  and  nuclei  are  swollen,  there  is  some  edema,  and  the  tissue  is 
infiltrated  with  small  round  cells.     On  the  left,  gland  epithelium  is  seen,  the  cells  are  somewhat  of 
the  goblet  shape,  and  are  secreting  mucus. 


GLAND    HYPERTROPHY 

Various  forms  of  hypertrophy  of  the  endometrium,  formerly  thought  to  be  the 
result  of  inflammation  and  called  endometritis,  are  now  known  to  be  the  result 
of  circulatory  changes.  Until  recent  years  all  hypertrophied  endometrium  was 
generally  supposed  to  be  a  pathologic  process.  Scientific  study  has  shown  that 
the  endometrium  undergoes  a  definite  physiologic  cycle  of  hypertrophy  each 
month  corresponding  to  the  menstrual  congestion.  This  change  is  characterized 
by  a  general  thickening  of  the  membrane.  The  stroma  is  swollen  by  a  congestion 
of  the  blood-vessels  and  by  an  edematous  exudate  in  the  spaces  between  the 
cells,  while  the  glandular  acini  are  longer  and  arranged  in  spiral  forms.  This 
process  begins  shortly  before  the  menstrual  flow,  reaches  its  height  during  the 
flow,  and  then  gradually  subsides,  to  be  repeated  at  the  next  catamenial  period. 
The  premenstrual  and  postmenstrual  hypertrophy  is,  therefore,  physiologic  and 
common  to  a  greater  or  less  degree  to  all  menstruating  endometria.  (See  also 
page  24.)  The  hypertrophy  may,  under  certain  conditions,  be  permanent  or 
excessive,  and  it  must  then  be  regarded  as  pathologic,  though  it  does  not  neces- 
sarily cause  symptoms.     When  the  hypertrophy  becomes  extreme  the  mucous 


250 


GYNECOLOGY 


membrane  is  thrown  into  folds  of  .varying  size.  This  process  is  called  polypoid 
gland  hypertrophy.  An  extreme  form  of  the  process  shows  great  thickening  of 
the  endometrium,  and  the  glands,  besides  being  long  and  spiral,  branch  out  and 
exhibit  a  true  hyperplasia.  This  type,  when  pronounced,  is  called  adenoma  of 
the  endometrium,  and  is  sometimes  difficult  to  distinguish  from  adenocarcinoma. 
The  glands,  however,  preserve  their  type  and  do  not  tend  to  dip  into  the  mus- 
cular tissue  of  the  uterus. 

It  may  be  said  in  general  that  the  endometrium  becomes  thickened  under 
conditions  of  prolonged  hyperemia  or  passive  congestion  of  the  genital  organs. 


Fig.  64.'— Gland  Hypertrophy  of  the  Endometrium. 
High  power.     The  glands  he  close  together,  the  stroma  cells  between  them  being  compressed. 
The  epithelium  is  high,  the  cells  active.    This  drawing  shows  especially  the  tuft-like  invagination  of  the 
epithelium  of  the  glands  into  the  lumen,  forming  a  connective-tissue  papilla  covered  with  epithelium. 

These  conditions  are  furnished  physiologically  by  the  menstrual  flux,  as  we  have 
seen.  Pathologically,  the  hypertrophy  may  be  the  result  of  misplacements, 
pelvic  inflammation,  ah  decidual  processes,  repeated  abortions,  extra-uterine 
pregnancy,  masturbation,  excessive  venery,  etc.  Sometimes  extreme  forms  of 
gland  hypertrophy  of  the  polypoid  and  adenomatous  type  exist  apparently  as 
an  independent  disease,  the  etiology  of  which  is  obscure. 

Gland  hypertrophy,  as  a  condition  secondary  to  pelvic  congestion  in  a  large 


GENERAL   INFLAMMATORY    PROCESSES  251 

percentage  of  cases,  gives  no  symptoms.  It  may  cause  a  moderate  leukorrhea 
from  the  oversecretion  of  the  endometrial  glands,  but  this  leukorrhea  is  not 
distinctive.  Uterine  pain  and  tenderness  are  often  given  as  symptoms  of  gland 
hypertrophy,  but  these  symptoms  are  more  likely  due  to  the  pelvic  condition  to 
which  the  hypertrophy  is  secondary.  The  most  important  manifestation  of 
gland  hypertrophy  is  menorrhagia.  Here,  however,  we  meet  with  difficulty  be- 
cause of  our  defective  knowledge  of  the  causes  of  menorrhagia,  and  we  cannot 
be  sure  that  the  hypertrophy  is  not  the  result  rather  than  the  cause  of  the  abnor- 
mal bleecUng. 

In  the  polypoid  and  adenomatous  types  of  hypertrophy,  leukorrhea,  menor- 
rhagia, uterine  pain  and  tenderness,  and  dysmenorrhea  may  appear  as  well-de- 
fined symptoms. 

Treatment. — Since  it  has  been  learned  that  the  hypertrophy  of  the  endo- 
metrium is  usually  either  physiologic  or  a  secondary  manifestation  which  does 
not  of  itself  often  give  symptoms,  there  is  not  much  to  say  concerning  special 
treatment  of  the  endometrium.  Attention  is  rather  directed  to  the  primary  pel- 
vic abnormalities. 

When  the  extreme  forms  of  polypoid  or  adenomatous  hypertrophy  occur  the 
object  of  treatment  is  to  control  the  menorrhagia,  which  may  be  very  severe 
and  depleting.  Drugs,  such  as  ergot,  hydrastin,  and  hamamelis,  are  practically 
useless.  Pituitrin  is  said  by  some  recent  writers  to  be  of  much  benefit,  especially 
in  the  treatment  of  young  girls.  Cureting  may  diminish  the  bleeding  temporar- 
ilj',  but  in  many  cases  the  hypertrophied  membrane  re-forms  rapidly  and  the 
cureting  has  to  be  repeated.  Sometimes  palliative  treatment  is  of  little  avail,  and 
in  order  to  prevent  the  continued  loss  of  blood  a  supravaginal  hysterectomy 
must  be  resorted  to.  Radiation  is  coming  to  be  of  great  value  in  these  cases,  but 
in  young  women  it  must  be  employed  with  caution  and  by  expert  hands  to  avoid 
destruction  of  the  ovarian  follicles,  with  consequent  sterility. 

METRITIS 

The  term  "metritis,"  like  endometritis,  is  somewhat  loosely  used  to  designate 
various  inflammatory  and  circulatory  changes  in  the  body  of  the  uterus.  Strictly 
speaking,  it  should  be  applied  only  to  such  inflammatory  conditions  as  result 
from  microbic  infection.  True  metritis,  when  it  does  occur,  is  most  commonly 
the  result  of  severe  puerperal  infection,  extending  from  the  endometrium  into 
the  tissues  of  the  uterine  body.  In  the  present  days  of  improved  obstetric 
technic  puerperal  metritis  is  not  often  met  with.  Outside  of  the  puerperium, 
infections  of  the  metrium  are  rare.  A  few  cases  have  been  reported  of  gonorrheal 
metritis,  while  tuberculosis  sometimes  extends  from  the  endometrium  to  the 
deeper  layers  of  the  uterine  body. 

The  treatment  of  infectious  metritis  belongs,  for  the  most  part,  to  the  realm, 
of  obstetrics.     It  is  primarily  conservative  and  expectant.     If  the  uterus  con- 


.252  GYNECOLOGY 

tains  infected  and  decomposing  material,  it  is  removed,  but  deep  curetage  is 
dangerous.  Extreme  cases  sometimes  require  rapid  total  hysterectomy  with 
drainage  of  the  pelvis. 

INFLAMMATIONS   OF  THE   OVARY 

The  subject  of  oophoritis  (or  ovaritis)  is  at  present  in  a  state  of  some  confusion, 
there  being  no  unanimity  among  writers  as  to  the  classification  of  the  various 
inflammatory  processes  of  the  ovary  or  to  the  clinical  interpretation  of  many  of 
the  anatomic  changes  that  take  place  in  the  ovarian  tissue.  We  are  obliged, 
therefore,  to  be  somewhat  arbitrary  in  treating  the  subject,  and  shall  classify 
inflammations  of  the  ovary  simply  under  the  headings  of  infectious  oophoritis 
and  interstitial  oophoritis. 

By  "infectious  oophoritis"  is  meant  those  conditions  of  the  ovary  which  result 
from  the  invasion  of  pathogenic  microorganisms.  It  includes  both  the  acute 
and  chronic  stages  of  the  infectious  process. 

By  the  term  "interstitial  oophoritis"  is  included  a  considerable  number  of 
somewhat  vaguely  understood  degenerative  conditions,  manifested  both  in  the 
stroma  and  epithelial  structure  of  the  ovaries,  and  resulting  from  constitutional 
disturbances,  old  inflammatory  processes,  or  circulatory  changes.  Interstitial 
oophoritis  is,  therefore,  not  a  true  inflammation  in  the  sense  of  being  an  infection 
of  microbic  organisms. 

INFECTIOUS   OOPHORITIS 

Of  the  direct  infections  of  the  ovaries,  that  from  puerperal  sepsis  is  the  most 
common,  the  streptococcus  being  the  most  frequent  invading  organism.  The 
way  by  which  the  ovaries  are  attacked  is  usually  from  a  pelvic  peritonitis.  In 
this  way  the  ovarian  surface  is  first  implicated  by  contact  with  the  inflamed 
peritoneum.  In  most  cases  the  albuginea  acts  as  an  efficient  barrier  to  prevent 
the  organisms  from  breaking  through  into  the  parenchymatous  tissue  of  the 
ovary,  so  that  the  process  remains  one  of  perioophoritis.  In  severe  cases,  how- 
ever, the  infection  may  enter  the  ovary  and  cause  an  acute  suppurative  oophori- 
tis. Cases  of  this  severity  are  usually  fatal,  but  if  the  patient  recovers  the 
ovaries  become  involved  in  dense  adhesions,  often  harboring  chronic  abscesses, 
until  the  infectious  process  gradually  dies  out  or  surgical  operation  intervenes. 
In  such  cases  the  ovaries  are  in  a  condition  of  true  chronic  oophoritis. 

Infection  from  puerperal  sepsis  may  enter  the  ovaries  by  other  ways  than 
through  the  surface  epithehum  and  albuginea.  Sometimes  the  invasion  may  be 
by  the  route  of  the  cellular  tissue,  from  the  parametrium  through  the  hilus  of  the 
ovary  into  the  ovarian  stroma.  According  to  Gebhard,  the  infection  may  reach 
the  ovaries  from  a  septic  puerperium  by  the  way  of  the  parametrial  blood-ves- 
sels as  a  result  of  septic  thrombosis. 

Outside  of  the  puerperium  the  greater  number  of  infections  of  the  ovary  are 


GENERAL   INFLAMMATORY    PROCESSES  ^253 

the  result  of  gonorrhea.  As  has  been  pointed  out  in  the  section  on  that  subject, 
the  surface  of  the  ovary  may  become  involved  in  the  general  peritonitic  process 
accompanying  gonorrheal  salpingitis,  or  the  inner  structure  of  the  ovary  may 
become  involved  in  suppuration  by  the  passage  of  infection  from  the  ostium 
of  the  tube  through  the  ruptured  opening  of  a  corpus  luteum  or  even  of  an  atretic 
follicle.  In  this  way,  as  was  shown,  are  formed  the  tubo-ovarian  abscesses. 
These  compound  abscesses  harbor  the  invading  organisms  longer  than  does  a 
simple  pyosalpinx,  so  that  the  disease  is  more  severe,  longer  in  duration,  and 
requires  more  radical  surgical  treatment. 

Tuberculosis  may  infect  and  include  the  ovary  in  a  general  suppurative  proc- 
ess, extending  from  the  tube  in  the  same  manner  as  gonorrhea.  Miliary  peri- 
toneal tuberculosis  may  affect  the  surface  of  the  ovary,  but  rarely,  if  ever,  in- 
vades the  ovarian  stroma  through  the  epithelial  covering  and  the  protective 
albuginea  layer,  though  occasionally  it  may  enter  the  opening  of  a  ruptured 
follicle.  Isolated  tuberculosis  of  the  ovary,  of  which  a  few  cases  have  been 
reported,  is  the  result  of  hematogenous  infection  from  a  distant  focus,  as  has 
been  shown  in  the  section  on  Tuberculosis  (g.  v.). 

The  ovary  in  the  form  of  an  ovarian  tumor  may  become  infected  as  a  result 
of  torsion  and  adhesion  to  the  intestine,  from  which,  as  a  result  of  necrosis, 
organisms,  usually  the  colon  bacillus  or  some  member  of  the  staphylococcus 
group,  convert  the  cyst  into  an  abscess.  The  surface  of  the  right  ovary  some- 
times becomes  infected  secondarly  to  acute  appendicitis,  especially  in  young 
girls. 

Infectious  oophoritis  sometimes  results  in  intra-ovarian  hemorrhages  with 
the  formation  of  blood-cysts,  a  subject  which  is  discussed  more  fully  in  the 
section  on  Ovarian  Tumors. 

Chronic  infectious  oophoritis  represents  the  part  taken  by  the  ovaries  in  a 
general  pelvic  inflammation,  and  can  hardly  be  regarded  as  a  disease  by  itself. 
The  symptoms  from  this  condition  are  due  to  immobilizing  peritoneal  adhesions, 
and  the  special  effect  on  the  ovaries  cannot  be  clinically  distinguished. 

Chronic  infectious  oophoritis  may  be  associated  with  or  be  converted  into 
the  interstitial  type. 

INTERSTITIAL   OOPHORITIS 

Interstitial  oophoritis  is  a  subject  which  we  must  treat  somewhat  apologet- 
ically, including  as  it  does  a  number  of  conditions  the  pathogenesis  of  which 
we  have  only  an  incomplete  knowledge. 

As  stated  above,  interstitial  oophoritis  does  not  represent  an  infectious 
process,  but  rather  one  of  tissue  degeneration. 

In  the  earlier  stages  there  is  a  general  increase  in  the  size  of  the  organ.  The 
interstitial  elements  are  hypertrophied.  There  is  a  hyperplasia  of  the  stroma 
cells  without  loss  of  their  distinctive  structure  and  also  a  well-marked  thicken- 
ing of  the  albuginea.      An  acute  stage  has  been  described  in  which  are  seen 


254  '  GYNECOLOGY 

clusters  of  small  round  cells  near  the  blood-vessels,  and  sometimes  an  edema 
pervading  the  lymph-spaces  between  the  stroma  cells. 

In  association  with  the  changes  in  the  interstitial  tissue  are  practically  always 
seen  signs  of  degeneration  in  the  parenchyma.  There  is  marked  diminution  in 
the  number  of  primordial  follicles  and  an  abnormal  tendency  to  atresia  and 
cyst  formation  of  the  riper  follicles  ("small  cystic  degeneration").  In  addition 
to  the  above  findings  there  can  usually  be  seen  a  thickening  of  the  vessels  in  the 
medullary  zone  of  these  ovaries,  so  that  they  appear  as  hyaline  masses,  indicat- 
ing a  tendency  to  obliterating  arteritis.  Later  stages  of  the  process  may  exhibit 
an  excessive  cyst  formation,  in  which  usually  one  cyst  develops  at  the  expense 
of  the  others,  and  converts  the  ovary  into  a  cystoma  of  greater  or  less  size. 
(See  Tumors  of  Ovary.)  The  cyst  formation,  according  to  Gebhard,  is  the 
result  of  an  inability  of  the  follicles  to  burst  on  account  of  the  resistance  of  the 
dense  albuginea  layer,  and  represents  a  thwarted  physiologic  function.  In 
other  cases  the  interstitial  elements  undergo  a  sclerotic  change,  the  parenchy- 
matous portions  disappear,  and  the  ovary  shrinks  into  a  small  fibrous,  atrophied 
structure  resembhng  that  of  old  age. 

The  etiology  in  some  cases  is  quite  clear,  while  in  others  it  is  entirely  obscure. 
Ovaries  that  have  long  been  buried  in  adhesions  often  exhibit  interstitial  oophori- 
tis. This  process,  though  the  secondary  outcome  of  a  previous  infection,  must, 
nevertheless,  be  regarded  not  as  inflammatory,  but  as  an  indication  of  degenera- 
tion resulting  from  interference  with  the  circulation  and  normal  function  of  the 
ovary.  Degeneration  of  the  ovaries  sometimes  occurs  after  acute  infectious  dis- 
ease like  typhoid,  septicemia,  small-pox,  cholera,  scarlet  fever,  and  severe 
intoxications,  such  as  are  caused  by  phosphorus,  arsenic,  etc.  The  degenera- 
tion may  be  so  complete  as  entirely  to  destroy  the  function  of  the  ovaries,  with 
consequent  amenorrhea  and  sterility.  Here  the  process  is  one  which  the 
ovaries  share  with  certain  other  organs  of  the  body  after  such  maladies,  and  is 
not  an  infection,  but  a  form  of  local  degeneration.  In  lactation  atrophy  and 
premature  senility  a  like  change  occurs  in  the  ovaries.  Other  etiologic  factors 
commonly  supposed  to  produce  ovarian  degeneration  have  their  basis  in  circu- 
latory disturbances.  Of  these  may  be  mentioned  chlorosis,  harmful  influences 
during  menstruation,  such  as  exposure  to  cold  or  violent  physical  exertion,  in- 
complete involution  of  the  uterus  after  childbirth,  circulatory  changes  from 
chronic  heart  disease,  sexual  irritation  from  masturbation  or  imperfect  coitus, 
extra-uterine  pregnancy,  and,  finally,  the  influence  of  pelvic  tumors,  especially 
of  uterine  fibroids.  Undoubtedly,  oophoritis  is  sometimes  found  associated 
with  ah  of  these  conditions,  but  in  our  present  state  of  knowledge  a  definite 
causal  relationship  between  the  two  must  be  accepted  with  reservation. 

The  symptomatology  of  infectious  oophoritis  is  identical  with  that  of  pelvic 
inflammation,  to  which  the  reader  is  referred  in  the  chapter  on  Gonorrhea. 

With  regard  to  the  symptomatology  of  interstitial  oophoritis  ideas  have 
within  recent  years  undergone  a  considerable  change.     We  now  know  that 


GENEEAL   INFLAMMATORY   PROCESSES  255 

atresia  of  the  follicles  is  physiologic,  and  that  a  certain  degree  of  small  cystic 
formation  is  to  be  found  in  practically  all  normal  ovaries  during  the  menstruat- 
ing period  of  life,  and  that  the  process  does  not  cause  pain.  Nor  is  pain  in  the 
ovary  itself  caused  by  an  abnormal  degree  of  cystic  degeneration,  even  to  the 
formation  of  a  retention  cystoma.  If,  however,  adhesions  are  present,  or 
there  is  torsion  of  the  enlarged  ovary  or  engorgement  of  the  broad  ligament 
veins,  pain  is  in  evidence.  Moreover,  sclerosis  of  the  ovaries  does  not  of  itself 
cause  pain.  Old  women  have  sclerotic  ovaries,  but  do  not  suffer  pain  from 
them.  It  is  probable  that  most  cases  of  so-called  ovarian  pain  result  from 
peritoneal  adhesions,  varicosities  in  the  broad  ligaments,  torsion  of  the  ovarian 
vessels,  possibly  the  drag  of  a  heavy  organ  on  the  ovarian  ligaments.  Of  these 
causes  peritoneal  adhesions  is  the  most  frequent.  They  cannot  always  be 
detected  even  by  the  most  expert  examination,  and  this  leads  frequently  to  such 
diagnoses  as  ''ovarian  neuralgia." 

Another  common  fallacy  is  that  cystic  degeneration  causes  "reflex"  nervous 
symptoms,  such  as  hysteria,  genital  psychoneuroses,  etc.  This  subject  is  dis- 
cussed in  the  section  on  Neurology. 

Interstitial  oophoritis  is  a  not  infrequent  cause  of  sterility,  as  would  be  ex- 
pected from  the  pathology  of  the  affection. 

The  treatment  of  infectious  oophoritis  is  that  of  pelvic  inflammation. 

The  treatment  of  interstitial  oophoritis  depends  on  the  associated  condi- 
tion which  causes  the  symptoms.  It  cannot  be  diagnosed  except  in  the  case 
of  abnormal  cyst  formation  when  surgical  interference  is  indicated,  the  opera- 
tion being  conservative  (resection)  or  radical  (oophorectomy),  according  to 
the  size  of  the  cyst.  The  resection  of  ovaries  which  show  moderate  cystic  de- 
generation is  a  useless  and  often  harmful  procedure. 

For  cases  of  premature  sclerosis  and  atrophy,  ovarian  extract  is  indicated. 

PARAMETRITIS  AND   PELVIC   CELLULITIS 

Anatomy  of  the  Pelvic  Cellular  Tissue. — Lying  beneath  the  pelvic  perito- 
neum is  a  complicated  intercommunicating  space  filled  with  a  somewhat  loose 
connective  tissue,  which  is  termed  the  ''pelvic  cellular  tissue."  This  tissue  partly 
surrounds  all  the  organs  of  the  pelvis.  In  it  are  embedded  the  ureters  and  the 
large  vessels  of  the  pelvis.  In  some  places  the  cellular  tissue  is  loose  and  filmy, 
a  characteristic  which  originally  gave  the  structure  its  name.  In  other  places 
it  is  denser  and  contains  smooth  muscle-fibers.  These  thickened  portions  con- 
stitute the  so-called  ligaments  of  the  uterus.  The  presence  of  muscular  fiber 
is  especially  well  marked  along  the  uterine  vessels  near  their  entrance  into  the 
uterus,  and  gives  the  tissues  at  these  points  such  firm  supporting  strength 
that  they  are  designated  the  cardinal  ligaments  of  the  uterus. 

Certain  parts  of  the  pelvic  cellular  tissue  are  characterized  by  special  names 
from  their  relationship,  to  various  organs.     Thus,  that  which  is  in  contact  with 


256  GYNECOLOGY 

the  uterus  is  called  parametrial;  that  near  the  bladder,  paracystic,  and  that  near 
the  rectum,  paraproctal.  Inflammations  of  these  portions  have  the  correspond- 
ing names  of  parametritis,  paracystitis,  paraproctitis,  etc.,  while  a  general 
term  including  any  form  of  inflammation  of  the  tissue  is  "pelvic  cellulitis." 

The  parametrial  cellular  tissue  surrounds  that  portion  of  the  uterus  and 
cervix  that  is  included  in  the  pelvic  diaphragm.  The  most  important  part  of 
it  lies  at  the  bases  of  the  two  broad  ligaments.  It  is  enclosed  by  the  leaves  of 
the  broad  ligaments  above  and  merges  into  the  wall  of  the  vagina  below.  In 
front  there  is  a  certain  amount  of  dehcate  parametrial  tissue  between  the 
bladder  and  its  reflection  on  the  anterior  wall  of  the  uterus.  Behind,  the  peri- 
toneum is  bound  closely  to  the  posterior  wall  of  the  uterus,  cervix,  and  vagina, 
so  that  there  is  little  parametrial  tissue  in  evidence. 

In  close  connection  with  the  parametrium  is  the  cellular  tissue  about  the 
bladder.  It  communicates  in  front  of  the  bladder  with  the  very  loose  fibers 
which  occupy  the  so-called  prevesical  space  or  space  of  Retzius.  Behind,  the 
parametrium  is  less  directly  connected  with  the  paraproctal  ceUular  tissue  in 
relation  with  the  rectum.  Between  the  rectum  and  vagina  is  found  a  layer  of 
the  tissue  which  communicates  behind  with  a  layer  between  rectum  and  sacrum. 
The  subperitoneal  cellular  space  reaches  out  laterally  to  the  abdominal  wall 
and  posteriorly  to  the  lumbar  vertebrae. 

Besides  these  comparatively  direct  communications,  the  tissue  ramifies  to 
other  areas  by  narrow  channels.  Thus,  it  connects  with  the  fat  of  the  ischio- 
rectal fossa  by  a  smafl  opening  between  the  ischiococcygeus  and  the  levator  ani 
muscles.  With  the  interstitial  connective  tissue  of  the  lower  extremities  a  com- 
munication exists  through  the  crural  arch  along  the  crural  vessels.  A  similar 
connection  with  the  gluteal  region  is  found  through  the  greater  ischiadic  open- 
ing; also  one  with  the  inguinal  region  along  the  round  ligament. 

The  area  occupied  by  the  pelvic  cellular  tissue  must  be  regarded  as  a  space 
through  which  infection  may  spread  along  lines  of  least  resistance,  or  which' 
extravasations  of  blood  may  permeate,  or  which  tumors  may  readily  dissect 
in  the  process  of  growth.  The  pathology  of  the  cellular  tissue  is,  therefore, 
classified  into  three  phases — inflammation,  hematoma,  and  tumor  formation. 
The  first  two  phases  will  be  discussed  in  this  section,  the  third  is  treated  in  the 
section  on  Tumors. 


INFLAMMATIONS   OF   THE   PELVIC   CELLULAR   TISSUE 

Infection  of  the  cellular  tissue  occurs  as  a  microbic  invasion  through  lymph- 
channels,  the  most  common  seat  of  infection  being  the  parametrium.  The 
inflammatory  process  may  remain  localized  or  it  may  spread  to  other  parts  of 
the  cellular  space.  It  usually  affects  the  overlying  peritoneum,  the  inflam- 
mation of  which  may  be  confined  to  the  local  area  or  spread  in  the  form  of  a 
general  peritonitis.     The  infectious  process  may  reach  no  further  than  the 


GENERAL   INFLAMMATORY    PROCESSES  257 

stage  of  infiltration,  or  it  may  progress  to  suppuration  of  the  most  extensive 
character.  Just  as  there  is  a  wide  range  in  the  pathologic  aspects  of  cellulitis, 
so,  in  the  chnical  picture,  the  disease  may  vary  from  one  of  mild  insignificance  to 
one  of  rapid  fatal  termination. 

Pelvic  cellulitis  practically  always  implies  a  thrombosis  of  the  veins  which 
pass  through  the  tissue  involved.  In  a  parametritis  the  thrombosis  may  be 
confined  to  the  branches  of  the  hypogastric  and  internal  spermatic  veins,  but 
it  may  extend  to  the  internal  iliac,  common  ihac  and  crural  veins,  and  even  to 
the  vena  cava. 

The  relationship  between  the  inflammatory  process  and  the  formation  of 
thrombi  is  not  a  constant  one.  Extensive  thrombosis  is  frequently  seen  in  con- 
nection with  slight  evidence  of  parametrial  infiltration  and  vice  versa.  The 
most  important  secondary  results  of  thrombosis  are  pulmonary  emboHsm  and 
the  edema  of  the  lower  extremity  in  cases  where  the  crural  vein  is  involved 
(phlegmasia  alba  dolens — milk  leg). 

If  the  inflammatory  process  of  the  cellular  tissue  progresses  to  local  suppura- 
tion the  abscess  may  break  through  into  neighboring  organs,  most  commonly 
the  vagina,  rectum,  or  bladder,  occasionally  into  the  cervical  canal. 

The  healing  of  celluhtis  results  in  dense  scar  formation,  which  may  cause 
serious  dislocation  and  immobihzation  of  the  pelvic  organs. 

The  interest  in  ceflular  inflammation  centers  chiefly  in  that  of  the  para- 
metrium. Parametritis  is  most  commonly  an  obstetric  disease,  infection  result- 
ing from  some  trauma  of  the  cervix  by  which  pathogenic  organisms  are  intro- 
duced, or  from  a  puerperal  septic  condition  of  the  endometrium  through  the 
lymph-channels  of  the  uterine  wall.  The  obstetric  aspects  of  parametritis  can- 
not be  treated  here. 

From  the  standpoint  of  gynecology,  parametritis  is  most  commonly  seen 
as  a  compfication  of  pelvic  operations.  The  operation  most  frequently  followed 
by  this  affection  is  that  of  hysterectomy  for  pelvic  inflammation,  in  which  there 
exists  some  active  infectious  process  in  the  subperitoneal  ceflular  tissue.  Just 
as  cellulitis  may  involve  the  overlying  peritoneum,  so  a  pelvic  peritonitis  may 
also  implicate  the  underlying  cellular  tissue.  Removal  of  the  pelvic  organs 
sometimes  lights  up  the  infection  of  the  ceflular  tissue,  and  local  sepsis,  usuafly 
in  the  parametrium,  results,  which  if  not  well  provided  for  by  competent  drain- 
age may  cause  the  backing  up  of  a  pelvic  abscess.  Postoperative  cellulitis  or 
parametritis  may  follow  any  pelvic  operation  in  which  the  ceflular  tissue  is 
infected  during  the  operation;  for  example,  the  parametrium  may  be  infected 
from  a  septic  endometrium  by  careless  handflng  of  the  uterus  during  a  hyster- 
ectomy operation.  A  parametritis  may  also  result  from  a  parametrial  hematoma 
that  later  becomes  infected. 

Minor  operations,  such  as  dilatation  and  curetment,  the  use  of  the  sound, 
and  operations  on  the  cervix,  if  performed  without  aseptic  precautions  have  been 
known  to  cause  parametritis.     Even  foreign  bodies  in  the  vagina,  which  cause 
17 


258.  GYNECOLOGY 

ulceration  and  local  infection,  may  transmit  the  inflammatory  process  to  the 
parametrium  through  the  lymph-channels.  Inflammation  of  the  parametrium 
from  these  latter  causes  are,  however,  rare. 

An  important  factor  in  the  causation  of  gynecologic  parametritis  is  the  in- 
fection from  necrotic  tumors  of  the  uterus  and  cervix,  such  as  sloughing  fibroids 
and  cancer.  Cancer  of  the  cervix  is  especially  prone  to  infect  the  parametrium, 
harboring,  as  it  always  does,  the  most  virulent  organisms.  This  point  is  of 
special  clinical  importance,  because  it  is  often  difficult  to  determine  by  palpation 
whether  a  parametrial  infiltration  is  due  to  the  extension  of  inflammation  or  of 
cancer,  and  on  this  point  often  rests  the  decision  as  to  whether  or  not  the  case 
is  operable.  It  is  possible  for  the  parametritis  foUowing  the  infection  of  cancer 
of  the  uterus  to  extend  to  the  pelvic  peritoneum  and  cause  a  local  or  even  a 
general  peritonitis. 

Rare  causes  of  parametritis  are  the  spreading  of  infection  from  appendicitis 
and  the  invasion  of  actinomycosis. 

Wertheim  gives  as  an  unusual  cause  of  parametrial  inflammation  the  deep 
invasion  of  the  gonococcus  through  the  peritoneum.  An  actual  gonococcal 
parametritis  is  probably  rare,  nevertheless  the  cellular  subperitoneal  tissue  is 
very  frequentty  found  edematous  and  inflamed  during  operations  for  pelvic 
inflammation  of  gonorrheal  origin.  Doubtless  the  invasion  of  the  cellular  tissue 
is  the  result  of  other  organisms  which  so  often  complicate  all  gonorrheal  infec- 
tions. 

Extensive  tuberculosis  of  the  pelvis  is  sometimes  attended  with  deep  infil- 
tration of  the  cellular  tissue. 

Symptoms. — The  chief  symptom  of  postoperative  parametritis  is  pelvic 
pain,  usually  more  on  one  side  than  the  other.  On  account  of  the  proximity 
which  the  process  has  to  the  bladder,  and  the  usual  extension  to  the  paracystic 
cellular  tissue,  there  are,  as  a  rule,  symptoms  of  irritable  bladder  with  the  pres- 
ence of  a  mild  cystitis.  There  is  always  some  elevation  of  temperature,  and  if 
suppuration  occurs  there  is  a  marked  rise  in  the  leukocytosis  and  an  increase  of 
local  symptoms. 

Postoperative  parametritis,  though  it  may  progress  to  a  fatal  termination, 
is  usually  not  a  particularly  dangerous  comphcation,  though  it  may  prolong  the 
convalescence  for  many  weeks.  If  there  is  suppuration,  and  evacuation  of  the 
pus  is  brought  about  either  spontaneously  or  by  secondary  operation,  a  rapid 
cure  usually  results.  Cases  in  which  the  parametrial  infection  is  of  the  infiltrat- 
ing, non-suppurative  type,  though  milder  in  their  course,  have  a  tendency  to 
recurrence  one  or  more  times  weeks  or  months  after  subsidence  of  the  first 
attack.  . 

A  very  chronic  form  of  parametritis,  compHcating  pelvic  inflammation  re- 
sulting from  salpingitis  and  adhesions  in  the  posterior  culdesac,  is  often  met 
with  during  pelvic  operations.  The  cicatricial  tissue  caused  by  this  comphca- 
tion is  exceedingly  dense,  and  greatly  increases  the  difficulty  and  danger  of  the 


GENERAL   INFLAMMATORY    PROCESSES  259 

operation.  This  condition  is  almost  invariably  met  with  when  a  previous 
posterior  colpotomy  has  been  performed  for  the  evacuation  of  a  tubal  abscess, 
and  it  is  for  this  reason  that  the  latter  operation  is  to  be  avoided  excepting  as  a 
life-saving  measure. 

The  chronic  form  of  parametritis  is  also  frequently  encountered  during  the 
extended  operation  for  cervical  cancer,  a  complication  which  makes  the  isola- 
tion of  the  ureters  and  uterine  vessels  extremely  difficult.     Patients  who  have 
had  radium  treatment  usually  show  the  cicatricial  form  of  parametritis  to  a 
greater  or  less  extent. 

The  cicatricial  type  of  chronic  parametritis  is  termed  ''parametritis  atrophi- 
cans" (Freund)  and  "parametritis  posterior"  (Schultze). 

Postoperative  parametritis  is,  as  a  rule,  easily  detected  by  digital  examina- 
tion. The  cervix  is  entirely  immobilized,  and  there  is  a  hard  board-like  feel  to 
the  surrounding  tissues  which  is  entirely  characteristic,  and  simulated  only 
by  the  infiltration  of  malignant  disease  or  by  a  parametrial  hematoma.  The 
indurated  area  is  situated  on  one  or  both  sides  of  the  cervix,  reaching  to  the 
pelvic  wall,  very  often  extending  around  to  the  front  if  the  paracystic  tissue  is 
involved.  It  is  usually  tender.  Suppuration  is  indicated  by  increased  swelling 
and  softness  of  the  mass,  associated  with  rise  in  the  leukocyte  count  and  aggra- 
vation of  the  constitutional  symptoms. 

A  differential  diagnosis  between  infectious  parametritis  and  postoperative 
parametrial  hematoma  cannot  always  be  made.  Hematoma  is,  as  a  rule,  les^ 
tender,  constitutional  reaction  is  less  marked,  and  the  leukocyte  count  is  lower 
or  absent. 

Parametritis  associated  with  cancer  of  the  cervix,  if  of  the  chronic  exuda- 
tive type,  cannot  well  be  differentiated  from  infiltration  of  the  malignant  dis- 
ease. If  the  process  is  more  acute  the  patient  has  well-defined  symptoms  of 
pelvic  inflammation.  Such  patients  should  not  be  operated  on,  nor  should  they 
receive  radium  treatment,  which  not  only  tends  to  aggravate  the  inflammatory 
process,  but  also  intensifies  the  malignity  of  the  cancerous  disease.  The  use 
of  radium  not  infrequently  of  itself  produces  an  inflammatory  reaction  in  the 
parametrium,  which  makes  radical  operation  immediately  following  radium 
treatment  exceedingly  dangerous  as  regards  postoperative  sepsis  (see  also  Radium 
Treatment  of  Cancer). 

The  treatment  of  postoperative  parametritis  is  usually  palliative  because  in 
most  cases  the  process  tends  to  absorption  rather  than  to  suppuration.  The 
best  treatment  is  rest  in  bed  with  frequent  hot  vaginal  douches.  Absorption 
under  treatment  may  take  place  in  a  few  days,  but  may  require  several  weeks, 
sometimes  months.  If  suppuration  occurs  the  abscess  must  be  opened  and 
evacuated,  usually  by  a  vaginal  incision.  Sometimes  a  postoperative  para- 
metrial abscess  may  be  evacuated  by  careful  dilatation  of  the  canal  of  the  cervi- 
cal stump.  If  there  has  been  vaginal  drainage,  enlarging  the  drainage  opening 
may  be  all  that  is  necessary. 


260  GYNECOLOGY 

Extensive  dissecting  abscesses  may  require  more  than  vaginal  drainage. 
In  some  cases  they  may  best  be  opened  by  an  incision  near  the  groin,  through 
which  the  peritoneum  is  stripped  back  without  entering  the  abdominal  cavity, 
so  that  the  abscess  may  be  evacuated  extraperitoneally.  It  may  even  be  neces- 
sary to  attack  the  disease  by  incision  in  the  gluteal,  perineal,  or  ischiorectal 
regions. 

Septic  cellulitis  may  follow  pelvic  operations  and  originate  in  other  parts 
of  the  cellular  space  than  the  parametrium.  We  have  seen  two  cases  of  exten- 
sive cellulitis  in  the  lateral  wall  of  the  abdomen  and  pelvis  follow  shortening  of 
the  round  ligaments  by  the  Mayo  method.  Suprapubic  operations  on  the 
bladder  may  result  in  sepsis  of  the  cellular  tissue  and  cause  a  dissecting  abscess 
reaching  to  the  lumbar  region.  Other  instances  might  be  enumerated.  The 
treatment  of  these  abscesses  can  sometimes  be  carried  out  successfully  by  con- 
servative measures,  but  in  general  it  is  best  to  open  them  by  the  most  advan- 
tageous route. 

PARAMETRIAL   HEMATOMA 

Parametrial  hematoma,  though  not  an  inflammatory  disease,  is  treated  here 
because  of  its  close  association  with  parametritis.  The  hematoma  results  from 
some  trauma  which  has  caused  a  hemorrhage  into  the  parametrial  tissue.  Being 
partially  confined,  the  extravasated  blood  soon  clots  and  forms  a  dense  tumor. 
The  tumor  may  be  restricted  to  the  parametrial  region,  or  it  may  dissect  its  way 
through  the  cellular  space  upward  as  far  as  the  region  of  the  kidney,  forming  an 
immense  tumor.  Severe  parametrial  hematomata  are  most  frequently  seen 
as  an  obstetric  complication,  following  laceration  of  the  cervix  into  the  broad 
ligament,  with  rupture  of  veins  in  the  parametrial  tissue. 

In  gynecologic  practice  extensive  hemorrhages  into  the  cellular  tissue  may 
occur  during  the  enucleation  of  intrahgamentous  or  postperitoneal  growths. 
The  accident  is  discovered  by  the  appearance  of  a  rapidly  increasing  tumor  in 
the  flank,  with  evidences  of  shock  on  the  part  of  the  patient.  Such  a  hemor- 
rhage may  be  fatal,  or  the  blood  may  soon  clot  and  the  patient  be  little  the 
worse  for  the  accident. 

Postoperative  parametrial  hematoma  is  by  no  means  uncommon,  especially 
after  supravaginal  hysterectomy.  The  comphcation  is  due  to  incomplete  hemo- 
stasis  and  postoperative  oozing  of  blood  into  the  parametrial  space.  Fre- 
quently it  entirely  passes  notice  unless  the  patient  receives  a  vaginal  examina- 
tion before  leaving  the  hospital.  In  other  instances  the  convalescence  lacks 
smoothness.  The  temperature  continues  to  be  slightly  elevated  and  the  pa- 
tient experiences  some  pelvic  discomfort.  Sometimes  the  patient  within  a  few 
hours  after  operation  passes  through  a  temporary  period  of  shock  with  very 
rapid  pulse,  for  which  the  attendants  are  unable  to  account. 

Vaginal  examination  of  a  patient  with  parametrial  hematoma  reveals  a 
hard  board-like  induration  adjacent  to  the  cervical  stump  and  complet-ely  im- 


GENERAL   INFLAjVI^L^TORY    PROCESSES  261 

mobilizing  it.  The  induration  may  extend  forward  into  the  paracj'stic  region; 
sometimes  it  extends  to  the  pelvic  wall. 

The  hematoma  is  usually  slow  in  absorbing,  and  maj^  remain  weeks  or 
months  in  the  pehds  before  its  disappearance.  Sometimes  it  becomes  infected 
and  converted  into  a  parametrial  abscess. 

The  treatment  of  parametrial  hematoma  is  primarily  prophylactic,  and 
consists  in  taking  extreme  care  in  hgating  all  bleeding  points  during  the  opera- 
tion of  hysterectomy,  or,  better  still,  to  perform  the  operation  in  such  a  way 
that  there  will  be  no  bleeding.  The  maneuver  shown  on  page  722,  of  closing  the 
peritoneum  over  the  cervical  stump  in  such  a  way  that  there  will  be  oppor- 
tunity for  drainage  back  into  the  peritoneal  ca\'ity  of  slight  oozing,  is  a  good 
l^reventive,  for  blood  is  much  more  readily  absorbed  from  a  peritoneal  surface 
than  from  the  parametrial  tissue. 

When  a  hematoma  has  been  formed  surgical  interference  is  practicalh^  always 
contraindicated.  The  treatment  should  be  conservative,  as  in  the  exudative 
form  of  parametritis,  and  consists  in  rest  and  the  frequent  application  of  hot 
douches.  If  the  hematoma  becomes  infected  the  treatment  then  becomes  that 
of  suppurating  parametritis. 

URETHRITIS 

Acute  urethritis  is  almost  exclusively  the  result  of  gonorrheal  infection,  and 
has  been  described  in  the  chapter  on  Gonorrhea  {q.  v.).  The  infection  is 
usually  primary  and  appears  after  a  short  incubation  period.  There  is  at  first 
discomfort,  then  intense  burning,  on  micturition.  The  meatus  becomes  swollen 
and  hyperemic,  while  the  entrances  to  the  ducts  of  Skene's  glands  become  red 
and  sw^ollen.  A  thick  j^ellow  pus  appears,  and  occasionally  there  is  bleeding 
from  ulceration  or  fissure  of  the  urethral  membrane.  The  acute  stage  of  the 
disease  passes  quickly.  The  pus  becomes  thinner  and  more  scanty,  and  the 
disease  either  heals  spontaneously  or  passes  on  into  the  chronic  stage,  which 
maj^  last  for  months  or  years.  Gonorrheal  urethritis  may  come  and  go  without 
producing  noticeable  s^nnptoms.     (See  also  section  on  Gonorrhea.) 

Chronic  urethritis  may  be  the  end-result  of  an  acute  gonorrheal  attack,  or 
the  gonorrheal  infection  may  be  of  the  chronic  type  from  the  first.  Chronic 
urethritis  maj^  also  be  primarih^  the  result  of  infection  from  other  organisms  than 
the  gonococcus,  those  most  commonly  found  being  the  colon  bacillus  and  the 
staphylococcus.  It  is,  however,  very  difficult  to  say  in  a  given  case  whether  the 
original  infection  was  or  was  not  gonococcal,  for  in  a  chronic  urethritis  which 
remains  from  an  acute  gonorrheal  attack  various  pathogenic  organisms  may  be 
found  without  the  presence  of  the  gonococcus.  Primary  colon  bacillus  urethritis 
doubtless  occurs,  but  its  frequency  is  problematic. 

Chronic  urethritis  is  localized  in  certain  portions  of  the  urethra,  not  often 
involving  the  entire  canal. 

The  principal  symptom  of  chronic   urethritis  is  burning  on  micturition. 


262  GYNECOLOGY 

Its  long  and  intractable  persistence  usually  has  a  deleterious  effect  on  the 
general  nervous  system,  especially  if  the  patient  thinks  herself  infected  with  a 
venereal  disease. 

Treatment  is  by  the  local  apphcation  of  5  per  cent,  silver  nitrate  to  the 
urethra,  and  requires  time  and  patience. 

Periurethral  abscess  is  usually  secondary  to  inflammation  of  Skene's  glands, 
and  occupies  the  anterior  vaginal  wall  in  its  lower  third.  It  communicates  by 
a  small  opening  with  the  urethral  canal,  into  which  it  intermittently  discharges. 
The  abscess  contents  may  change  in  time  to  a  thin  or  serous  character  and  the 
condition  become  painless,  so  that  the  swelhng  may  be  mistaken  for  a  vaginal 
cyst.  The  diagnosis  can  be  made  by  the  ability  to  evacuate  the  tumor  into  the 
urethral  canal. 

The  treatment  is  removal  of  the  abscess  or  cyst  sac  by  careful  cHssection. 
The  opening  into  the  urethra  must  be  treated  by  the  methods  used  for  vesical 
and  urethral  fistula. 

Stricture  of  the  urethra  is  not  a  common  affection  among  women.  It  is 
usually  the  result  of  gonorrhea,  but  may  be  due  to  the  injuries  of  childbirth. 
Urethral  stricture  is  not  infrequently  seen  in  women  with  marked  genital 
atrophy,  the  process  simulating  that  which  takes  place  in  the  cervix  with  con- 
sequent atresia. 

The  symptoms  are  difficulty  and  discomfort  in  urination. 

The  treatment  is  usually  simple,  and  consists  either  in  gradual  dilatation 
under  cocain  or  rapid  dilatation  under  full  anesthesia.  The  severe  cicatricial 
form  of  stricture,  which  is  rare,  may  require  annular  dissection  of  the  scar 
tissue. 

Kelly  recommends  electrolysis,  by  the  method  of  Newman,  as  a  routine 
method  of  treating  intractable  stricture. 

CYSTITIS 

Cystitis,  in  its  strictest  sense,  relates  to  an  infection  of  the  bladder  wall  by 
pathogenic  organisms.  The  existence  of  a  cystitis  is  demonstrated  by  the 
presence  of  infectious  bacteria  and  the  products  of  inHammation  in  the  urine. 
The  mere  presence  of  bacteria  in  the  urine  does  not  constitute  a  cystitis,  for  it 
has  been  shown  that  quantities  of  germs  may  be  introduced  into  the  bladder 
without  harmful  effect,  while  it  is  a  common  occurrence  that  patients  with 
septic  processes  in  the  kidneys  for  long  periods  of  time  pass  urine  that  is 
loaded  with  bacteria  without  infecting  the  bladder. 

In  order  to  create  a  cystitis,  bacteria  must  find  a  point  of  entry  into  the 
tissues  of  the  bladder  wall  through  the  lining  epithehum.  This  entrance  may 
be  gained  either  by  a  lesion  of  the  bladder  wall  or  by  some  condition  in  which 
there  is  a  lessened  resistance  on  the  part  of  the  mucous  membrane.  Injuries 
of  the  bladder  mucosa  may  be  caused  by  traumatism  during  operations,  or  in- 


GENERAL    INFLAMMATORY    PROCESSES  263 

strumentation,  or  by  unskilful  catheterization.  The  lesion  itself  does  not  con- 
stitute a  cystitis,  but  prepares  the  way  for  infectious  organisms.  Invasion  of 
the  bladder  by  bacteria  may  result  from  the  trauma  of  vesical  stones,  or  from 
inflammatory  processes  of  neighboring  organs,  which,  by  contact  and  adhesions, 
involve  the  bladder  wall.  The  resistance  of  the  bladder  mucosa  may  be  lowered 
by  the  irritation  of  chemical  substances  excreted  in  the  urine,  such  as  results 
from  the  ingestion  of  cantharides,  asparagus,  fermented  hquors,  etc.,  or  it  may 
be  caused  by  the  long  retention  of  urine  from  cystocele  or  stricture  from  pelvic 
tumors.  Severe  colds  and  physical  exhaustion  also  lower  the  resistance  of  the 
bladder  to  infection.  Conditions  of  lowered  resistance  do  not  necessarily  lead 
to  cystitis,  but  they  merely  predispose  the  organ  to  infection.  They  are  prob- 
ably an  infrequent  etiologic  factor  in  the  disease. 

The  irritation  of  ammoniacal  urine  is  a  very  definite  cause  for  bacterial  infec- 
tions, the  chemical  change  being  usually  brought  about  by  bacterial  action.  A 
very  great  number  of  bacteria  have  been  named  as  excitants  of  cystitis,  the  most 
important  being  the  Coh  communis,  proteus  Hauser,  streptococcus,  staphjdo- 
coccus,  pyocyaneus,  tubercle  bacillus,  typhoid  bacillus,  and  rarely  the  gono- 
coccus.  There  may  be  combined  or  mixed  infections,  especially  in  the  presence 
of  the  tubercle  bacillus.  The  reaction  differs  also  with  various  exciting  organ- 
isms, the  urine,  for  example,  being  alkahne  with  the  proteus  Hauser  and  acid 
with  the  staphylococcus  or  colon  bacillus  infections. 

Routes  of  Infection. — The  chief  route  of  invasion  by  infectious  organisms 
is  through  the  urethra.  It  has  been  a  matter  of  considerable  debate  as  to  whether 
spontaneous  ascending  infection  takes  place  through  the  urethra.  This  has 
been  generally  denied  in  the  male,  but  thought  to  be  possible  in  the  female 
on  account  of  the  shorter  and  less  comphcated  urethral  canal.  It  has  been 
pointed  out,  however  (Stoeckel),  that  the  entrance  of  bacteria  to  the  bladder 
is  conditioned  on  the  integrity  of  the  sphincter  vesicae  muscle,  which  under 
normal  conditions  is  as  efficacious  in  women  as  it  is  in  men.  In  women,  on  the 
other  hand,  there  is  far  greater  opportunity  for  injury  to  the  muscle,  such  as 
results  from  childbearing,  cystocele,  and  general  conditions  of  prolapse,  so 
tkat  it  much  more  frequently  becomes  relaxed  and  affords  an  avenue  of  entrance 
for  bacteria  from  the  urethra  and  vestibule. 

The  most  common  means  of  infecting  the  bladder  through  the  urethra  is  by 
catheterization.  This  may  be  accomplished  by  carrjdng  organisms  into  the 
bladder  on  an  unclean  catheter,  or  it  may  be  done  by  transferring  bacteria 
from  the  vestibule  and  meatus  on  a  catheter  that  has  been  properly  sterihzed. 
Postoperative  cystitis  following  catheterization  and  introduction  of  organisms 
depends,  to  a.  great  extent,  on  the  amount  of  trauma  done  to  the  bladder 
during  operation.  Aside  from  the  actual  accidental  tearing  or  cutting,  the 
bladder  wall  may  be  injured  in  a  variety  of  ways  not  always  appreciated  by 
the  surgeon  during  a  difficult  pelvic  operation.  Kelly  calls  attention  to  the 
furrowing  and  infiltration  of  blood  seen  in  the  mucosa  of  the  posterior  wall  fol- 


264  GYNECOLOGY 

lowing  the  method  sometimes  used  of  stripping  the  bladder  by  gauze  dissection 
from  the  cervix  and. vagina  during  a  hysterectomy  operation.  The  careless 
clamping  and  tying  of  vessels  in  the  bladder  wall  may  cause  local  injuries  or 
congestions,  which  sometimes  develop  minute  ulcerations  or  desquamations  of 
the  lining  epithelium  resulting  from  extravasations  of  blood  (Stoeckel).  These 
may  serve  as  ports  of  entry  for  bacteria  introduced  by  catheterization. 

Cystitis  is  especially  common  after  labor  because  of  the  frequency  of  injury 
to  the  bladder  by  the  passage  of  the  head  and  the  necessity  for  catheteriza- 
tion. It  is  noticeable  that  patients  who  have  suffered  from  postpartum  cystitis 
are  especially  prone  to  develop  the  condition  after  later  labors  or  pelvic  opera- 
tions which  involve  the  bladder,  such  as  hysterectomy  or  anterior  colpoplasty. 

It  has  been  shown  that  the  hyperemic  state  of  the  bladder  wall  during 
childbirth  is  especially  favorable  to  the  growth  of  invading  organisms,  as  are 
all  conditions  of  pelvic  congestion,  such  as  may  result  from  menstruation,  large 
pelvic  tumors,  adnexal  disease,  masturbation,  and  too  frequent  coitus. 

Another  means  of  infection  of  the  bladder  is  by  the  descending  route  from 
the  kidneys,  though,  as  has  been  stated,  pus  in  the  urine  from  infected  kidneys 
may  exist  for  a  long  time  without  causing  cystitis. 

There  seems  to  be  no  doubt  that  infection  may  be  carried  to  the  bladder 
wall  by  the  route  of  the  blood  circulation — so-called  hematogenous  infection. 
Undoubtedly,  some  of  the  cases  of  colon  cystitis  have  thus  been  contracted 
from  congestion  and  stasis  of  the  intestines.  The  cystitis  that  sometimes  fol- 
lows acute  infectious  diseases,  like  tj^phoid,  malaria,  and  influenza,  in  which 
the  specific  organism  can  be  demonstrated  in  the  urine,  undoubtedly  results 
from  a  hematogenous  infection. 

There  seems  to  be  no  question  also  that  micro-organisms  may  reach  the 
bladder  through  the  lymph-channels,  either  from  the  large  intestine  or  from 
infections  of  the  pelvic  genital  organs. 

Cystitis  may  also  be  caused  directly  by  the  rupture  into  the  bladder  cavity 
of  a  tubal  abscess  or  dermoid  cyst  or  purulent  diverticulitis. 

A  somewhat  frequent  secondary  inflammation  of  the  bladder  is  that  which 
results  from  a  parametritis,  the  organisms  probably  entering  the  bladder  wall 
through  the  lymph-channels.  This  is  seen  both  in  puerperal  sepsis  and  in  the 
postoperative  parametritis  that  occasionally  follows  hysterectomy  operations, 
especially  those  for  extensive  purulent  pelvic  inflammation. 

The  spontaneous  infection  of  an  ascending  gonorrheal  urethritis  is  probably 
rare.  The  organism  has  been  demonstrated  in  acute  cystitis  by  Wertheim  and 
Young,  so  that  gonorrheal  cystitis  unquestionably  exists.  It  is  probable,  how- 
ever, that  in  most  cases  the  disease  is  transferred  to  the  bladder  by  ill-considered 
instrumentation  or  treatment  of  the  urethral  canal. 

Pathology. — The  mucosa  of  acute  cystitis  has  a  characteristic  appearance  of 
general  reddening,  injected  branching  blood-vessels,  and  edematous  thickening 
of  the  membrane,  with  ecchymoses  and  erosions,  seen  most  commonly  at  the 


GENERAL   INFLAMIV^ATORY   PROCESSES  265 

trigonum.  The  inflammatory  process,  as  a  rule,  does  not  affect  the  entire 
bladder  wall  equally,  the  floor,  including  trigonum  and  fundus,  being  the  chief 
seat  of  the  infection.  According  to  Kelly,  in  the  acute  stages  there  is  com- 
paratively little  loss  of  epithehum.  Severe  inflammatory  processes  may,  how- 
ever, take  place,  with  very  general  necrosis  of  the  cpithehal  layers,  forming  so- 
called  croupous  or  diphtheritic  membranes,  or  even  reaching  the  muscularis  and 
causing  gangrene  of  the  bladder.  Gangrene  results  in  sloughing  of  the  inner 
lining  of  the  bladder,  with  consequent  thinning  of  the  wall  and  possible  rupture 
or  extension  of  the  inflammation  to  the  peritoneum  (Kiistner).  Heahng  of  this 
condition  results  in  great  shrinking  of  the  organ.  A  special  appellation,  used 
by  Kelly  for  conditions  of  sloughing  of  the  bladder  waU,  is  exfoliative  cystitis. 

In  the  chronic  stages  of  cystitis  the  changes  are  very  numerous.  Certain 
proliferations  of  the  epithehum  may  take  place,  producing  granular,  warty,  or 
polypoid  elevations  of  the  surface,  to  which  special  names,  as  cystitis  vegetans, 
verrucosa,  and  polyposa,  have  been  given.  Metaplastic  conditions  of  the 
epithehum  characteristic  of  leukoplakia  and  xerosis  are  seen  which  are  said  to 
lead  to  cancer  of  the  bladder  (Albarran).  The  proliferating  papillomatous  forms 
of  cystitis  can  sometimes  be  differentiated  with  difficulty  from  true  new-growth 
papillomata,  the  transition  from  one  condition  to  the  other  being  gradual.  In 
some  cases  there  occurs  a  dipping  down  or  infolding  of  the  mucous  membrane, 
with  the  ultimate  creation  of  gland-hke  inclusions.  The  epithehum  hning  these 
pseudoglands  becomes  modified,  and  resembles  the  mucosa  of  the  intestinal 
tract.  The  inclusions  may  form  cysts,  which  in  the  female  bladder  often 
break  down,  ulcerate,  and  become  incrusted  with  calcium  salts  (Kelly).  The 
gland  inclusions  are  doubtless  the  original  seat  of  adenocarcinoma  of  the 
bladder. 

It  has  been  pointed  out  (Zuckerkandl)  that  isolated  cysts  may  occur  in  nor- 
mal bladders,  but  that  the  condition  is  pathologic  when  they  become  multiple 
or  diffuse.     The  affection  has  been  termed  cystic  cystitis  and  herpes  vesicw. 

Simple  or  solitary  ulcer  of  the  bladder  occurs  usuafly  on  the  posterior  waff, 
and  resembles  somewhat  tubercular  ulceration.  The  cause  of  simple  ulcer  is 
thought  to  be  from  local  trophic  injury  to  the  bladder  wall  by  thrombosis  of  a 
■vein.  Stoeckel  has  observed  them  after  pelvic  operations  where  vessels  had 
been  tied  in  the  wall.  These  ulcers  are  sometimes  made  by  inexpert  cystoscopy. 
The  capacity  of  the  bladder  may,  as  a  result  of  chronic  inflammation,  be- 
come greatly  diminished  by  a  cicatricial  change  in  the  bladder  waU,  with  con- 
sequent shrinking  of  the  organ,  or  by  a  concentric  hypertrophy  of  the  tissues  of 
the  wall.  The  shrunken  bladder  is  most  commonly  the  result  of  neglected 
vesical  tuberculosis,  secondary,  as  a  rule,  to  tuberculosis  of  the  kidneys.  The 
waff  is  stiff  and  unyielding,  neither  dilatable  to  its  full  extent  nor  able  to  con- 
tract to  its  normal  limits. 

Paracystitis  relates  to  an  inflammation  of  the  connective  tissue  about  the 
bladder,  the  infection  of  which  may  have  come  from  a  cystitis  or  from  a  para- 


266  GYNECOLOGY 

metritis.  Purulent  paracystitis  may  extend  for  a  long  distance  in  the  sub- 
peritoneal cellular  tissue  and  may  result  fatally. 

Pericystitis  is  an  inflammation  of  the  peritoneum  covering  the  pelvic  portion 
of  the  bladder.  It  may  result  from  cystitis  or  from  a  general  pelvic  inflamma- 
tory disease,  by  which  the  adnexa  or  anterior  wall  of  the  uterus  or  intestines 
become  attached  to  the  bladder.  As  a  rule,  however,  the  anterior  half  of  the 
pelvis  is  peculiarly  free  from  infection  in  adnexal  disease,  so  that  the  bladder  is 
only  occasionally  involved. 

Symptoms  and  Course. — The  characteristic  symptoms  of  acute  cystitis  are 
pain,  dysuria,  frequency  of  urination,  and  pus  in  the  urine.  The  bladder  is 
tender  and  sensitive  to  abdominal  and  vaginal  palpation  and  to  the  passage  of 
the  catheter.  The  dysuria  in  cystitis  is  usually  distinctive,  in  that  the  pain  is 
severe  just  before  micturition  and  is  relieved  by  the  act,  that  of  urethritis  being 
most  severe  during  urination.  The  completion  of  urination  is  attended  with 
tenesmus.  If  the  affection  is  severe  and  there  is  great  frequency,  the  condition 
of  the  patient  may  be  one  of  almost  constant  strangury.  The  pain  often  radiates 
into  the  vagina,  rectum,  and  legs.  The  symptoms  are  most  distressing  at 
night  on  account  of  disturbance  of  rest  and  sleep  by  the  incessant  need  of  mic- 
turition. 

In  the  acute  stages  there  is  usually  fever  which  may  reach  a  considerable 
height.  The  fever  recedes  with  the  subsidence  of  the  acute  disease,  but  if  after 
careful  treatment  it  still  remains  elevated,  one  must  search  for  other  causes, 
especially  an  ascending  infection  to  the  kidney  pelvis. 

Acute  cystitis  under  rest  and  proper  treatment,  as  a  rule,  heals  after  vari- 
ous exacerbations,  but  it  may  exceptionall}^  develop  into  the  chronic  form 
(Stoeckel). 

Symptoms  of  chronic  cystitis  are,  in  general,  the  same  as  those  described  for 
the  acute  form,  though  less  intensive,  except  in  the  cases  of  contracted  blad- 
der, when  distressing  symptoms  may  continue  for  long  periods  of  time.  Bleed- 
ing is  comparatively  rare  in  cystitis  unless  it  is  associated  with  stone  or  tumor 
formation. 

A  possible  complication  of  cystitis  is  an  ascending  infection  resulting  in 
pyelitis  or  pyelonephritis.  Occasionally  the  inflammation  may  extend  to  the 
peritoneum  or  paracystic  tissue,  or  may  send  embolic  thrombi  into  the  circu- 
lation with  the  production  of  a  pyemia. 

The  duration  of  chronic  cystitis  may  be  indefinite,  resisting  all  forms  of 
treatment  and  lasting  for  years. 

The  diagnosis  of  acute  cystitis  is  not  a  difficult  one,  as  the  clinical  picture  is 
very  characteristic,  consisting  of  severe  pain  and  frequent  necessity  of  micturi- 
tion, with  distressing  tenesmus,  a  sense  of  fulness  and  pressure  in  the  pelvis, 
tenderness  of  the  bladder  region,  rise  of  temperature,  and  presence  of  pus  in  the 
urine  which  is  usually  neutral  or  alkaline.  A  very  similar  picture  is  presented 
in  acute  gonorrheal   urethritis  which  can,  as   a   rule,  be  differentiated  from 


GENERAL   INFLAMMATORY    PROCESSES 


267 


cystitis  by  the  appearance  of  gonorrheal  pus  exuding  from  the  urethra  and  by 
the  two-glass  urine  test,  the  second  urine  being  clear  in  urethritis. 

•  The  diagnosis  of  chronic  cystitis  is  a  much  less  simple  matter.  The  subjec- 
tive symptoms  are  less  characteristic  and  cannot  always  be  distinguished  from 
those  that  result  from  pressure  or  traction  from  affections  of  neighboring  organs. 
The  examination  of  the  urine  affords  only  incomplete  evidence.  The  cloudy 
appearance  of  a  urine  that  has  not  been  freshly  voided  is  misleading  on  account 


Fig  65.^-Unusual  Result  of  an  Exfoliative  Cystitis,  which  has  Caused  Plastic  Adhesions 
OF  THE  Bladder  Wall,  with  Great  Contraction  of  the  Bladder. 
The  adhesions  are  being  severed  in  order  to  give  greater  capacity  to  the  bladder.     Through  the 
cystoscope  the  appearance  was  that  of  multiple  diverticula.     (Operation  by  Dr.  F.  A.  Pemberton 
at  Free  Hospital  for  Women.) 


of  the  possibility  of  urates  or  phospates  or  bacteria  causing  the  cloudiness.  If 
the  freshly  passed  or  catheterized  urine  is  cloudy  the  condition  is  pathologic. 
If  pus  is  found  by  microscopic  examination  an  inflammation  is  evidently  present, 
but  its  location  is  not  indicated,  as  it  may  come  from  an  infection  higher  up. 
Washing  out  the  bladder  gives  some  information  as  to  whether  the  condition  is 
one  of  cystitis  or  pyelitis.  In  cystitis  the  wash-water  soon  returns  clear,  and 
will  remain  clear  for  some  time,  while  in  pyelitis  there  is  an  early  reappearance 
of  pus. 


268  GYNECOLOGY 

Though  cHnical  observations  give  a  more  or  less  valuable  clue  to  the  nature 
and  location  of  the  disease,  a  definite  diagnosis  can  only  be  made  with  the  cysto- 
scope.  In  acute  cystitis  cystoscopy  is  entirely  contraindicated  on  account  of 
the  danger  of  aggravating  the  inflammation,  but  in  chronic  cystitis  it  is  essen- 
tial for  diagnosis  and  often  for  treatment. 

The  cystoscope  will  reveal  the  presence  or  absence  of  an  inflammation  of 
the  urethra,  while  a  simple  pyehtis  may  usually  be  determined  by  exudation  of 
pus  from  the  ureteral  oriflce,  associated  with  a  normal  bladder  wall.  The 
changes  of  the  bladder  wall  are  numerous,  as  has  already  been  stated,  and 
consist  chiefly  of  various  grades  of  vascularization,  from  intensive  infection  of 
the  blood-vessels  to  diffuse  bright  or  dark  red  coloring  of  the  tissues,  in  which 
the  distinct  outlining  of  the  blood-vessels  entirely  disappears.  The  glistening 
appearance  of  the  normal  mucous  membrane  is  lost  and  the  surface  appears  dull. 
The  mucosa  from  edema  often  has  a  puffy  and  granular  character.  The  purulent 
secretion  is  either  attached  to  the  wall  in  shreds  or  floats  freely  in  the  fluid  con- 
tained in  the  bladder. 

In  advanced  cases  defects  of  the  epithehum  take  place,  with  consequent 
ulcers  with  irregular  flat  edges.  These  ulcers  on  healing  cause  sharp  cicatricial 
ridges  which  interfere  with  the  elasticity  and  contractility  of  the  bladder  wall. 

The  lesions  of  cystitis  rarely  occupy  the  whole  of  the  bladder  wall,  but  are, 
for  the  most  part,  confined  to  the  floor  of  the  bladder,  trigonum,  and  fundus,  the 
vertex  being  comparatively  free  from  infection.  As  a  rule,  also,  the  inflamma- 
tory areas  occur  in  scattered  irregular  patches,  sometimes  in  spots  or  petechise. 

Prophylaxis. — In  the  postoperative  conduct  of  gynecologic  cases  cystitis 
may,  to  a  great  extent,  be  prevented  by  proper  regard  to  catheterization.  The 
use  of  the  catheter  should  always  be  avoided  if  possible,  but  the  fact  remains 
that  the  majority  of  patients  recovering  from  pelvic  or  plastic  operations  require 
one  or  more  catheterizations.  This  must  usually  be  done  by  the  nurse,  but  if 
she  is  properly  trained  or  instructed  infections  from  the  use  of  the  catheter  may 
be  reduced  almost  to  nil. 

The  following  is  the  technic  employed  at  the  Free  Hospital  for  Women:  Under  aseptic 
precautions  the  vestibule  and  meatus  are  thoroughly  wiped  with  1  :  1000  corrosive  solution  on 
sterile  gauze.  A  glass  female  catheter  with  slight  curve  at  the  end  is  attached  to  a  sterile 
foimtain  syringe  containing  2  per  cent,  boric  solution  or  sterile  water,  the  receptacle  containing 
the  fluid  being  held  a  short  distance  above  the  level  of  the  patient.  When  the  catheter  is  about 
to  be  introduced  into  the  meatus  the  solution  is  allowed  to  flow  until  the  end  of  the  catheter 
reaches  the  bladder,  when  it  is  turned  off  and  the  rubber  tube  of  the  syringe  is  detached  from  the 
catheter.  When  the  urine  has  been  completely  drained  from  the  bladder  the  catheter  is  drawn 
gently  out,  with  the  thumb  over  the  open  end  to  prevent  the  dropping  of  urine  as  it  is  extracted. 
Every  motion  in  introducing  and  withdrawing  the  catheter  must  be  made  with  extreme  gentle- 
ness so  as  not  to  injure  the  bladder  mucous  membrane. 

The  glass  catheter  is  the  best  form.  The  surface  is  smooth  and  non-irritating  and  it  can 
most  easily  be  sterilized  and  kept  sterile.  Its  special  advantage  over  a  rubber  catheter  is  that  it 
can  be  introduced  by  grasping  it  well  away  from  the  end,  while  a  rubber  catheter  on  account 
of  its  lack  of  stiffness  must  be  taken  in  the  fingers  near  the  end  of  entrance,  thus  adding  an 


GENERAL    INFLAMMATORY    PROCESSES  269 

f^lement  of  danger  of  infection.  Metal  catheters  have  sharp  edges  at  the  openings  and  easily- 
become  rusted,  so  that  there  is  greater  danger  of  injuring  the  dehcate  mucous  membrane  of  the 
urethra  and  bladder. 

The  treatment  of  acute  cystitis  is  pre-eminently  heat  and  warmth.  The 
patient  should  be  kept  strictly  in  bed  and  applications  of  moist  or  dry  heat  kept 
over  the  bladder  region.  Moist  heat  is  the  most  effective,  and  can  best  be 
applied  with  pads  of  wool  soaked  in  hot  normal  salt  solution,  by  which  method 
the  frequent  changes  are  not  likely  to  cause  maceration  of  the  skin,  as  is  the 
case  with  cotton  pads  and  plain  water. 

In  order  to  relieve  pain,  codein  or  opium  rectal  suppositories  are  indicated, 
subcutaneous  injections  of  morphin  being  avoided  excepting  in  extreme  cases. 

Kelly  calls  attention  to  the  importance  of  determining  as  soon  as  possible  the  exciting  or- 
ganism, showing  that  the  treatment  should  be  varied  according  to  the  kind  of  bacterium  found. 
To  quote  Dr.  Kelly: 

"We  are  able  here  to  distinguish  five  different  forms  of  treatment,  according  as  they  are 
apphed  to  one  or  other  of  these  groups  of  infecting  organisms :  for  example,  when  tubercle  baciUi 
are  found,  the  general  practitioner  may  safely  conclude  at  once  that  the  trouble  is  quite  cer- 
tainly renal  in  its  origin  and  surgical  in  its  treatment.  Gonococcal  cystitis  will  disappear  under 
the  use  of  oil  of  copaiba  or  the  oil  of  sandalwood.  The  colon  bacillus  and  the  typhoid  bacillus 
are  more  affected  by  urotropin  taken  in  doses  of  3  to  15  or  20  grains  four  times  a  day,  according 
to  the  toleration — big  doses,  if  they  do  not  ii'ritate  the  bladder,  are,  as  a  rule,  most  efficient. 
The  diphtheria  bacillus  (rarely  found)  calls  for  the  administration  of  antitoxin.  If  the  proteus 
is  found  and  the  urine  is  alkaline,  give  benzoic  acid  in  doses  of  10  to  15  grains  to  make  it  acid, 
and  then  follow  this  with  urotropin.  Staphylococci  and  streptococci  also  call  for  the  use  of 
urotropin." 

A  bland  diet  must  be  imposed  in  which  alcoholic  drinks  and  highly  seasoned 
food  is  strictly  prohibited.  The  patient  is  encouraged  to  drink  large  quantities 
of  water,  the  numerous  mild  alkaline  waters  being  especially  recommended. 
When  the  more  acute  sjnxiptoms  have  subsided  the  best  method  of  medication 
is  the  use  of  urotropin,  cystogen,  or  helmitol,  the  efficiency  of  which  depends  on 
the  liberation  of  formaldehyd  in  the  urine.  In  order  that  the  fomaldehyd  be 
freed  it  is  necessary  that  the  urine  be  strongly  acid.  It  is,  therefore,  important 
to  change  the  reaction  of  neutral  or  alkaline  urines  by  the  use  of  benzoate  of 
soda  (doses  of  10  to  15  grains),  or  by  combining  with  the  urotropin  acid  sodium 
phosphate  in  10-grain  doses. 

In  the  acute  stage  of  cystitis  all  forms  of  local  treatment  of  the  bladder 
are  strongly  contraindicated.  When,  however,  the  more  severe  symptoms  have 
passed,  bladder  lavage  is  of  much  assistance. 

The  treatment  of  chronic  cystitis  is  extremely  varied,  and  depends  on  the 
character  and  duration  of  the  disease.  The  treatment  is  one  that  requires 
experience  and  judgment,  for  if  not  intelhgently  carried  out  the  disease  may 
drag  on  indefinitely,  becoming  progressively  worse. 

The  first  step  is  to  rule  out  the  possibility  of  infection  from  disease  higher 


270  GYNECOLOGY 

up  in  the  urinary  tract.  This  can  only  be  done  by  expert  cystoscopy,  cathe- 
terization of  ureters,  and  a:;-ray  photographs  of  the  kidney,  pelvis,  and  ureters. 
It  will,  of  course,  be  found  that  in  a  large  percentage  of  cases  the  origin  of  the 
trouble  is  from  above,  and  that  the  essential  treatment  must  be  aimed  in  that 
direction. 

If  the  diagnosis  of  chronic  cystitis  is  established  the  treatment  is  carried 
out  according  to  the  indications  discovered  by  the  cystoscope.  For  cases 
of  general  diffuse  inflammation  not  tubercular,  bladder  douches  are  indicated, 
together  with  the  medication  mentioned  above. 

The  solutions  most  commonly  used  for  bladder  lavage  are  2  per  cent,  boric 
acid,  silver  nitrate  (1  :  10,000  to  5000),  and  a  pale-pink  solution  of  permanganate 
of  potash.  Of  these,  the  boric  acid  is  the  least  irritating  and  the  safest  to  use,, 
though  not  as  effective  as  silver  nitrate.  In  giving  lavage  of  the  bladder  care 
must  be  taken  not  to  distend  the  bladder  too  much  at  first,  for  this  not  only 
causes  pain,  but  may  open  up  new  avenues  of  infection.  After  washing  out  the 
bladder  it  is  best  to  leave  in  some  of  the  solution,  to  be  voided  by  the  patient 
about  one-half  hour  later. 

Another  method  of  treating  the  bladder  is  by  instillations,  which  consists 
of  injecting  small  amounts  of  some  solution  into  the  bladder  and  leaving  it  there 
for  a  certain  period  of  time.  The  solutions  most  commonly  used  for  this  pur- 
pose are  silver  nitrate  (1  :  1000),  protargol.  (5  per  cent.),  and  argyrol  (30  per 
cent.) . 

Kelly  recommends,  gradual  distention  of  the  bladder  for  certain  cases  when 
the  capacity  has  become  very  limited.  The  treatment  is  carried  out  by  a  series 
of  irrigations  by  which  the  amount  of  fluid  injected  into  the  bladder  is  progress- 
ively increased  until  the  bladder,  at  first  capable  of  holding  only  30  or  50  c.c.,, 
is  made  to  contain  200  or  300  or  even  500  c.c.  of  fluid.  The  treatment  requires 
great  care  and  patience.  A  chart  is  kept  to  show  the  daily  increase  of  bladder 
capacity  (see  Kelly  and  Burnam,  Vol.  II,  p.  464). 

The  treatment  of  localized  areas  of  inflammation  or  ulceration  is  best  car- 
ried out  by  the  local  application  of  silver  nitrate  through  an  open-air  cystoscope, 
with  the  patient  in  the  knee-chest  position. 

Curetage  for  small  ulcerated  conditions  can  be  carried  out  through  a  large 
cystoscope,  care  being  taken  not  to  injure  the  ureteral  orifices,  or  it  may  be  done 
through  a  suprapubic  opening  into  the  bladder. 

In  severe  long-standing  cases  of  chronic  cystitis  it  may  be  necessary  to  give 
the  bladder  a  complete  rest.  This  may  be  done  either  by  constant  drainage  or 
by  creating  an  artificial  fistula.  Constant  drainage  is  carried  out  in  the  ordinary 
way,  it  being  advisable  to  use  a  glass  catheter,  preferably  that  recommended 
by  Skene.  The  relief  produced  by  permanent  drainage  is  in  some  cases  remark- 
able. The  bladder  should  be  irrigated  once  or  twice  each  day.  Still  more 
marked  is  the  result  of  an  artificial  vesicovaginal  fistula.    This  is  done  by  mak- 


GENERAL    INFLAMMATORY    PROCESSES  271 

ing  an  incision  through  the  vesicovaginal  septum  posterior  to  the  internal  ure- 
thral orifice.  The  drainage  can  be  maintained  in  two  ways — either  an  opening 
is  made  large  enough  for  the  introduction  of  a  self-retaining  glass  catheter 
which  is  sewed  in  place,  or,  preferably,  an  incision  about  f  inch  long  is  made 
and  the  mucous  membrane  of  the  bladder  and  vagina  sewed  to  prevent  too 
rapid  closure  (see  page  815).  By  the  latter  method  the  urine  drains  out  con- 
tinually, as  in  a  case  of  traumatic  fistula.  It  is  best  to  keep  these  patients  in  a 
hospital  until  the  disease  has  subsided  in  its  severity,  when  they  may  be  allowed 
to  go  home  and  be  more  or  less  active.  If  the  perineum  is  tight  it  is  necessary 
to  enlarge  it  so  that  the  vaginal  introitus  is  funnel  shaped,  otherwise  the  urine 
is  damned  back  in  the  vagina  and  bladder  with  injurious  results.  The  final 
results  of  vaginal  drainage  are  excellent.  There  need  be  no  fear  of  making  the 
opening  into  the  bladder  on  the  ground  of  a  possible  irremediable  fistula,  for 
it  will  be  found  that  there  is  usually  some  trouble  in  keeping  the  fistula  from 
closing  spontaneously.  If  it  does  not  close  of  itself,  the  operation  of  closure 
is  practically  always  successful,  for  there  is  not,  as  in  traumatic  fistula,  a  loss 
of  tissue,  formation  of  cicatrices,  and  difficulty  in  approximating  wound  edges 
without  tension. 

When  cases  of  ulceration  of  the  bladder  have  resisted  all  treatment,  a  radical 
excision  can  be  performed  through  a  suprapubic  incision. 

TUBERCULOSIS   OF  THE  BLADDER 

Tuberculosis  of  the  bladder  is  practically  always  secondary  to  some  other 
primary  focus  in  the  body.  In  women  the  infection  is,  with  few  exceptions, 
secondary  to  .renal  tuberculosis,  the  disease  never  passing  from  the  genital  to  the 
urinary  tract,  as  it  does  in  men.  Renal  tuberculosis  may  exist  for  years,  even 
in  a  destructive  form,  before  the  bladder  becomes  chronically  affected.  On  the 
other  hand,  the  cystitis  may  assume  an  early  and  acute  type,  causing  the  most 
distressing  and  intractable  symptoms,  such  as  have  been  described  above.  The 
pathologic  changes  in  the  bladder  wall  range  from  disseminated  tubercles  of  the 
mucous  membrane,  through  various  stages  of  ulceration  involving  the  bladder 
wall  more  or  less  deeply,  to  rare  cases  of  extensive  destruction  of  the  wall  and 
invasion  of  the  paravesical  tissues. 

The  diagnosis  of  a  suspected  case  of  tuberculosis  of  the  bladder  is  directed 
to  a  search  for  the  primary  disease  in  the  offending  kidney,  and  this  can  at  the 
present  time  usually  be  accomplished  successfully  by  catheterization  of  the 
ureters,  x-ray  photographs,  and  renal  functional  tests. 

The  treatment  of  vesical  tuberculosis  consists  in  the  removal  of  the  diseased 
kidney  if  the  other  kidney  is  not  affected,  information  of  which  can  be  definitely 
established  by  the  above-named  methods  of  examination. 

If  the  disease  in  the  bladder  is  not  too  severe,  extirpation  of  the  kidney  suf- 


272  GYNECOLOGY 

fices  for  a  complete  cure.  Without  removal  of  the  kidney  a  cure  is  practically 
out  of  the  question.  If,  after  nephrectomy,  the  disease  still  persists,  the  various 
methods  described  above  for  treating  chronic  cystitis  are  available,  especially 
that  of  drainage  through  a  vesicovaginal  opening.  If  only  a  locahzed  residuum 
remains,  it  can  be  exsected  through  a  suprapubic  incision.  In  the  most  ex- 
treme cases  the  bladder  has  been  completely  extirpated  and  the  ureters  im- 
planted in  the  bowel.  Kelly  recommends  the  simpler  method  of  cutting  off  the 
ureters  and  implanting  them  in  bowel  or  skin,  preferably  the  latter. 

When  the  disease  is  far  advanced  and  relief  from  surgical  measures  is  out  of 
the  question,  the  patient  is  to  be  treated  like  an  inoperable  cancer  case,  with 
doses  of  morphin  sufficiently  large  to  prevent  suffering. 

SYPHILIS   OF   THE   BLADDER 

Syphihs  of  the  bladder  is  a  very  rare  affection,  having  been  recognized 
definitely  only  a  comparatively  few  times.  The  manifestations  are  of  the  ter- 
tiary type,  and  appear  as  papillomatous  elevations  or  as  ulcerations  without 
distinctive  characteristics.  The  diagnosis  is  made  by  a  positive  Wassermann 
test,  the  improvement  of  the  condition  under  salvarsan,  or  by  finding  the  Spiro- 
chaeta  palhda  in  a  piece  of  the  gummatous  growth  excised  for  microscopic  exam- 
ination. 

CYSTITIS   VETULARUM    (OLD   WOMEN) 

Inflammation  of  the  bladder  is  common  in  old  women,  and  is  a  result  of 
general  local  atrophy  which  causes  so  many  other  disturbances.  The  shrinking 
of  the  tissues  about  the  vaginal  introitus  affects  the  meatus,  which  is  gradually 
drawn  inward  toward  the  vagina,  often  resulting,  as  we  have  seen  elsewhere,  in 
a  partial  prolapse  of  the  urethral  mucous  membrane.  The  protecting  labia 
minora  shrink  up  and  disappear,  and  the  vaginal  orifice,  losing  its  former  elas- 
ticity, remains  stiffly  open.  Thus,  the  urethra  is  by  its  position  exposed  to  in- 
fections from  a  senile  vaginitis  or  from  fecal  contamination.  The  cystitis  that 
ensues  is  a  result  of  direct  transmission  of  pathogenic  bacteria  through  the 
urethra  to  the  bladder  mucous  membrane.  The  resistance  of  the  bladder  to 
infection  is  greatly  lessened  in  old  women  as  a  consequence  of  the  atrophied 
anemic  condition  of  the  mucosa  and  the  diminished  elasticity  and  capacity  of  the 
bladder  wall.  ^  These  aged  patients  suffer  greatly  from  the  frequent  necessity 
of  urination,  often  from  actual  incontinence,  by  which  their  rest  is  incessantly 
disturbed.  Patients  of  the  better  class  are  much  distressed  by  the  constant 
odor  of  decomposing  urine  that  pervades  the  room  in  which  they  live.  Many 
of  these  patients  are  sufferers  from  other  affections,  such  as  rheumatism  or 
bronchial  catarrh,  and  dread  afl  local  manipulation,  so  that  treatment  is  very 
difficult.      Hot  bladder   douches  give   the   most    relief  if  they  can  be  given. 


GENERAL    INFLAIVIjVIATORY    PROCESSES  273 

Occasionally  the  incontinence  can  be  reKeved  by  the  skilful  application  of  a 
pessary. 

Bladder  irritation  usually  occurs  in  old  women,  in  the  absence  of  bacterial 
infection,  as  a  result  of  the  senile  changes  in  the  bladder  wall,  which  reduce  its 
capacity  and  contractility.  The  symptoms  are  increased  micturition  and 
cloudy  urine,  the  appearance  in  the  urine  being  due  to  desquamation  of  the 
lining  epithelium.  These  patients  are  often  remarkably  relieved  by  an  occa- 
sional bladder  douche  given  in  amount  sufficient  to  distend  moderately  the 
contracting  bladder  wall. 

PYELITIS 

Pyehtis  relates  to  a  bacterial  infection  of  the  mucous  membrane  of  the 
pelvis  of  the  kidney.  It  represents  a  milder  form  or  preliminary  stage  of  the 
more  extensive  inflammations  of  the  kidney  that  pass  under  the  names  of 
pyelonephritis,  suppurating  kidnej^,  and  kidney  abscess.  The  distinction  be- 
tween pyehtis  and  the  more  severe  forms  of  kidney  inflammation  is,  therefore, 
one  of  clinical  convenience  rather  than  of  any  essential  pathologic  difference. 

Pyelitis  bears  an  important  relationship  to  gynecology  in  many  ways, 
chief  of  which  are  the  comparative  frequency  of  the  disease  as  a  complication 
in  the  convalescence  from  gynecologic  operations,  and  in  the  course  of  preg- 
nancy or  the  puerperium;  its  connection  with  gonorrhea;  and  the  role  that  it 
plays  in  certain  phases  of  gynecologic  diagnosis.  The  knowledge  of  pyelitis  has 
been  greatly  increased  by  the  use  of"  the  cystoscope,  and  it  has  been  found  that 
the  disease  is  much  more  common  than  was  formerly  supposed,  many  cases 
that  were  before  thought  to  be  cystitis  now  being  shown,  by  more  exact  methods 
of  diagnosis,  to  be,  in  reality,  inflammations  of  the  pelvis  of  the  kidney. 

The  mode  of  entrj'-  of  bacteria  to  the  kidney  has  been  a  subject  of  much  dis- 
cussion and  experimental  work,  and  it  is  now  known  that  infection  may  take 
place  either  through  the  agency  of  the  blood  circulation,  the  hematogenous 
route,  or  from  the  bladder  upward  through  the  ureteral  canals — the  urogenous 
route. 

Infection  by  the  hematogenous  or  descending  route  is  by  far  the  more 
common,  as  has  been  proved  both  by  clinical  and  experimental  evidence.  In- 
fection by  the  ascending  route  of  cases  is  evidenced  by  clinical  observations, 
but  has  not  yet  been  established  by  scientific  experimentation. 

The  pathogenic  bacteria  responsible  for  pyelitis  are  pre-eminently  the  Coli 
communis,  and  of  secondary  frequency  the  staphylococcus,  streptococcus,  pro- 
teus,  and  probably  the  gonococcus.  In  addition  to  these,  numerous  other 
special  organisms  have  been  described  that  are  either  very  rare  or  are  possibly 
modified  forms  of  the  more  common  bacteria.      In  acute  cases  the  staphylo- 

18 


274  GYNECOLOGY 

COCCUS,  streptococcus,  and  proteus  are  more  frequently  present,  while  in  chronic 
cases  it  is  usual  to  find  the  colon  bacillus  in  pure  culture  (Kelly). 

The  presence  of  bacteria  in  the  blood  and  their  excretion  in  the  urine  does 
not  necessarily  betoken  an  infection  of  the  kidney  or  its  pelvis,  for  pathogenic 
organisms  may  pass  through  the  kidneys  for  long  periods  of  time  without 
doing  local  damage.  Infection  is  consequent  on  some  condition  that  lowers  the 
resistance  of  the  organ,  such  as  might  result  from  a  systemic  disease  or  some 
local  interference  with  the  excretory  function.  Contributory  to  pyehtis  and  the 
other  kidney  infections  are  pyemia,  septicemia,  ulcerative  endocarditis,  pneu- 
monia, and  the  acute  infectious  diseases.  Local  causes  are  stone  and  hydro- 
nephrosis resulting  from  external  pressure  on  the  ureters,  such  as  is  exerted  by 
tumors.  Pregnancy  and  postoperative  sepsis  are  especially  important  factors 
in  causation.  Ascending  infections  of  the  kidney  pelvis  are  apt  to  follow  condi- 
tions of  urinary  retention  in  the  bladder,  or  inflammatory  bladder  lesions  that 
affect  the  tissue  at  the  openings  of  the  ureters. 

The  etiology  of  the  pyelitis  that  complicates  pregnancy  and  the  puerperium 
has  not  been  definitely  determined.  It  is  supposed  that  the  resistance  of  the 
kidney  is  lowered  by  retention  from  pressure  of  the  gravid  uterus  on  the  ureters 
or  bladder,  and  that  the  infection,  which  nearly  always  is  the  colon  bacillus,  takes 
place  through  the  blood  route  from  the  intestines,  which  are  apt  to  be  in  a  con- 
dition of  stasis  favorable  for  the  absorption  of  bacteria. 

Pyelitis,  complicating  gynecologic  operations  can  be  explained  in  no  other 
way  than  by  a  hematogenous  infection  from  a  septic  focus  at  the  seat  of  the 
operation.  The  primary  focus  is  not  always-  apparent,  for  it  not  infrequently 
happens  that  pyelitis  follows  operations  the  wounds  of  which  heal  without 
appreciable  sepsis. 

It  is  a  matter  of  observation  that  surgical  operations  may  light  up  an  old 
pyelitis  conjbracted  during  pregnanpy'..  Investigators  are  divided  as  to  whether 
the  gonococcus  ever  causes  pyehtis.  An  ascending  infection  seems  improbable. 
If  the  cases  of  so-called  gonorrheal  pyelitis  are  authentic,  it  seems  more  likely 
that  the  gonococci  reached  the  kidney  by  the  hematogenous  route,  the  localiza- 
tion of  the  disease  in  the  kidney  being  analogous  to  gonorrheal  infections  of  the 
joints. 

Symptoms. — Acute  pyelitis  is  ushered  in  with  chills  and  high  fever.  The 
urine  contains  pus  and  albumin.  The  acute  attack  may  end  in  death,  or  the 
fever  may  recede  and  become  remittent,  or  the  disease  may  develop  into  the 
chronic  type.  Repetition  of  chills  and  exacerbations  of  temperature  signify 
usually  involvement  of  the  kidney  parenchyma  with  abscess  formation.  Pain 
and  tenderness  of  the  kidney  is  usually,  but  not  always,  present. 

Chronic  pyelitis  may  be  the  end-result  of  an  acute  attack,  but  more  com- 
monly starts  as  the  chronic  form  from  the  beginning. 
•    The  symptomatology  of  pyelitis  is  not  always  clearly  defined.     The  essential 


GENERAL    INFLAMMATORY    PROCESSES  275 

symptoms  are  pus  in  the  urine,  sensitiveness  of  the  kidney  region,  moderate 
swelhng  of  the  involved  kidney,  leukocytosis,  irritability  of  the  bladder,  and 
disturbances  of  the  general  health.  None  of  these  symptoms  are,  however,  to 
be  relied  upon.  A  pyelitis  may  exist  many  years  without  alteration  in  the 
health,  constitutional  changes  being  due  rather  to  the  gradual  involvement  of 
the  kidney,  which  evokes  the  symptoms  characteristic  of  diffuse  hematogenous 
nephritis. 

Sensitiveness  of  the  kidney,  as  shown  by  pain  or  tenderness,  is  present  in 
only  about  half  of  the  cases,  while  an  appreciable  enlargement  of  the  kidney, 
such  as  can  be  felt  by  manual  examination,  appears  in  only  about  one-quarter 
of  the  cases.  Dilatation  of  the  pelvis,  when  present,  is  due  to  some  obstruction 
or  dislocation  of  the  ureter,  which  may  in  some  cases  produce  an  intermittent 
enlargement  of  the  pelvis  like  that  seen  in  hydronephrosis. 

Cystitis  is  not  always  present,  as  the  infected  urine  may  pass  through  the 
bladder  for  a  long  time  without  exciting  inflammation.  Frequency  of  urination 
is,  however,  practically  always  present,  due  partly  to  chemical  irritation  of  the 
bladder  and  partly  to  the  fact  that  in  most  cases  of  chronic  pyelitis  there  is  an 
excretion  of  large  quantities  of  urine  (Kelly). 

As  far  as  the  examination  of  the  urine  goes,  the  presence  of  pus  is  the  only 
constant  sign.  The  reaction  is  usually  acid,  but  may  be  alkaline.  The  caudate 
epithelial  cells,  formerly  regarded  as  of  important  diagnostic  value,  are  now 
known  to  be  simulated  by  cells  from  the  deeper  layers  of  the  epithelium  lining 
the  lower  urinary  tract.  In  a  case  of  simple  pyelitis  the  amount  of  albumin  in 
the  urine  corresponds  only  to  the  pus  contents.  If  the  albumin  is  increased 
it  bespeaks  an  involvement  of  the  parenchyma  of  the  kidney — pyelonephritis. 
Renal  casts  are  not  found  in  simple  pyelitis,  and  their  appearance  signifies  a 
pyelonephritis,  though  their  absence  does  not  necessarily  rule  out  a  nephritis 
extension. 

Leukocytosis  is  usually  present,  but  there  are  exceptions  to  the  rule.  As 
pus  in  the  urine  is  the  only  constant  sign,  the  final  diagnosis  of  pyelitis  must  be 
made  with  the  cystoscope.  In  a  pronounced  case  the  diagnosis  can  be  made  by 
observing  cloudy  urine  spurting  from  the  urethral  orifice.  The  ureters  are  then 
catheterized,  and  the  diagnosis  made  by  examination  of  the  two  specimens  of 
urine.  In  a  case  of  simple  pyelitis  the  functional  test  of  the  kidneys  shows  little 
or  no  difference  between  the  two  sides.  If,  however,  the  kidney  itself  is  impli- 
cated, the  diseased  side  will  always  show  retarded  function. 

Postoperative  Pyelitis. — The  clinical  course  of  the  postoperative  pyelitis 
which  frequently  occurs  as  a  comphcation  during  the  convalescence  from  gyne- 
cologic operations  is  so  characteristic  that  it  deserves  special  mention.  It  ap- 
pears more  frequently  after  abdominal  operations  than  after  simple  plastic  or 
external  operations,  although  it  may  occur  after  the  latter.  It  is  rather  more 
common  in  women  who  have  borne  children.    This  is  due  to  the  fact  that  pye- 


276  GYNECOLOGY 

litis  is  a  frequent  complication  in  the  puerperium  and,  as  has  been  stated,  a  patient 
who  has  once  passed  through  an  attack  is  extremely  liable  to  a  later  recurrence 
either  from  another  childbirth  or  from  a  surgical  operation,  even  though  it  be 
years  after  the  initial  attack.  A  close  examination  of  the  histories  of  all  patients 
who  develop  a  postoperative  pyelitis,  whether  they  have  borne  children  or  not, 
will  reveal  a  surprisingly  large  percentage  of  previous  attacks. 

The  time  of  onset  of  pyelitis  following  surgical  operation  seems  to  character- 
ize two  types  of  the  disease.  In  one  the  initial  symptoms  appear  within  two  or 
three  days  following  the  operation.  In  the  other  the  symptoms  are  not  evident 
for  one  or  two  or  even  three  weeks  after  operation.  It  has  been  a  matter  of 
personal  observation  that  when  the  disease  appears  late  the  symptoms  are  more 
severe  and  last  somewhat  longer  than  when  it  develops  early. 

As  a  rule,  postoperative  pyelitis  comes  unexpectedly  in  a  patient  who  is 
making  an  otherwise  satisfactory  convalescence.  The  onset  may  be  mild  or 
severe.  In  the  mild  form  the  first  evidence  is  a  burning  on  micturition  with  a 
moderate  rise  of  temperature  and  a  general  sense  of  malaise.  The  urine  shows 
an  increase  of  leukocytes.  The  symptoms  increase  for  a  few  days  and  then 
subside.  Even  in  the  mild  form  the  temperature  may  rise  to  103°  F.  If  the  attack 
is  early  the  time  of  surgical  convalescence  may  not  be  prolonged  and  the  patient 
may  be  little  inconvenienced.  Such  a  patient,  however,  is  more  susceptible  to 
another  attack  if  she  undergoes  a  surgical  operation  at  some  later  date.  There 
is  also  possibility  of  recurrence  during  the  convalescence. 

In  the  severer  forms  the  attack  may  be  acute  and  often  alarming.  There 
may  be  sudden  intense  pain  on  micturition.  The  temperature  runs  a  characteris- 
tically high  course  for  one  or  two  days,  frequently  reaching  104°  and  105°  F.  In 
these  cases  the  kidneys  usually  show  evident  signs  of  the  disease.  One  or  both 
kidneys  may  be  palpably  enlarged,  tender,  and  painful.  Often  these  signs  appear 
first  in  one  kidney  and  then  in  the  other  as  the  first  subsides.  The  average 
course  in  the  severe  form  is  about  a  week,  though  pus  in  the  urine  persists  con- 
siderably longer.  Patients  are  subject  to  one  or  more  recurrences  with  inter- 
vals of  a  few  days  to  several  weeks. 

The  great  majority  of  postoperative  pyelitis  cases  get  well  without  leaving 
serious  injury  except  a  greater  susceptibility  to  the  disease. 

The  prognosis  of  pyelitis  is  variable.  A  simple  pyelitis  may  last  years  with- 
out encroaching  on  the  kidney,  but  it  may  extend  to  the  renal  parenchyma  and 
cause  pyelonephritis.  A  quiescent  pyelitis  is  very  apt  to  be  lighted  up  by  preg- 
nancy and  labor  or  by  surgical,  especially  gynecologic,  operations. 

The  prognosis  of  unilateral  affections  is  better  than  that  of  bilateral  disease, 
in  which  uremic  conditions  may  ensue. 

The  treatment  of  acute  pyelitis  consists  of  rest  in  bed,  hot  applications, 
abundant  ingestion  of  water,  and  urotropin. 

The  treatment  of  chronic  pyelitis  is  practically  the  same.     Cases  which 


GENEEAL    INFLAMMATORY    PROCESSES  277 

do  not  yield  to  general  medical  measures  can  often  be  cured  by  lavage  of  the 
renal  pelvis  with  solutions  of  silver  nitrate  (1  :  1000),  bichlorid  of  mercury 
(1  :  10,000),  and  formahn  (1  :  3000)  (Kelly),  the  solutions  being  made  some- 
what stronger  as  the  treatment  progresses.  Vaccine  therapy  has  been  recom- 
mended, but  most  observers  have  found  it  of  little  value. 

Surgical  procedures  for  the  relief  of  pyelitis  must  be  directed  toward  the 
removal  of  such  causative  conditions  as  pelvic  tumors  or  constriction  of  the 
ureters,  stones  of  the  renal  pelvis,  etc.  Surgical  operations  on  the  kidney  for 
simple  pyelitis  are  not  commonly  indicated.  Nephrotomy,  or  splitting  the 
kidney  and  leaving  it  open  for  drainage,  is  recommended,  especially  by  Casper, 
but  it  is  not  an  operation  in  general  favor.  Nephrectomy  is  indicated  in  those 
cases  where  an  intractable  cystitis  is  maintained  by  a  pyelitis,  and  which  does 
not  yield  to  non-surgical  treatment. 

INFLAMMATION   OF  THE  COLON 

DIVERTICULITIS 

An  important  affection  of  the  large  intestine  which  the  pelvic  surgeon  must 
bear  in  mind  in  the  diagnosis  of  acute  abdominal  conditions,  and  which  he  must 
be  prepared  to  treat  when  unexpectedly  encountered,  is  diverticulitis  of  the 
colon. 

Diverticulitis  is  a  disease  the  clinical  and  surgical  significance  of  which  has 
been  only  quite  recently  recognized,  though  anatomic  knowledge  of  acciuired 
intestinal  diverticula  has  existed  for  many  years. 

Sommering,  as  far  back  as  1794,  described  a  case  of  acquired  diverticula  of  the  small  intes- 
tine. In  1845  Gross  demonstrated  and  pictured  diverticula  in  the  large  intestine.  The  con- 
dition was  also  described  by  Klebs,  Alibert,  Schroder,  Sydney  Jones,  Astley  Cooper,  and 
others.  In  1896  Hanseman  found,  at  autopsy  of  a  man  of  eighty-five,  four  hundred  diverticula 
occurring  throughout  the  entire  length  of  the  intestines.  These  historic  cases  were  all  from 
autopsies  and  were  regarded  merely  as  anatomic  curiosities.  In  the  translation  of  Noth- 
nagel's  Encyclopedia,  pubhshed  as  recently  as  1904,  the  following  statement  is  made:  "As  these 
lesions  (acquired  diverticula)  are  chiefly  of  anatomic  interest  and  have  very  httle  chnical 
significance,  only  a  few  general  remarks  will  be  made  on  this  question." 

The  general  recognition  of  the  surgical  importance  of  the  subject  may  be  said  to  date  back 
only  a  few  years.  In  1906  Sampson  and  Gogornier  published  their  case  of  obstruction  from 
diverticuUtis  of  the  small  intestine,  and  called  attention  to  the  fact  that  acquired  diverticula  not 
only  occurred  more  frequently  than  is  supposed  by  pathologists,  but  that  they  are  the  unrecog- 
nized etiologic  factors  in  many  inflammatory  processes  of  the  intestine,  especially  those  occur- 
ring in  the  region  of  the  sigmoid.  In  1907  W.  J.  Mayo  pubUshed  5  cases  of  diverticuUtis  of  the 
sigmoid  and  at  that  time  was  able  to  collect  only  18  other  authentic  cases  from  the  hterature. 
Since  then  surgeons  and  pathologists  have  given  closer  attention  to  the  subject,  and  the  record 
of  cases  is  rapidly  increasing  both  in  the  operating  room  and  in  the  laboratory. 

Acquired  diverticula  are  to  be  distinguished  from  so-called  congenital  di- 
verticula, of  which  Meckel's  diverticulum  and  the  vermiform  appendix  are 


278  GYNECOLOGY 

the  most  familiar  examples.  It  was  formerly  supposed  that  the  acquired  variety 
results  from  an  actual  hernia  of  the  mucous  coat  through  the  fibers  of  the  mus- 
cles of  the  intestines,  and  the  term  "false  diverticula"  was  applied  to  them  by 
Cruveilhier  and  Rokitansky,  to  distinguish  them  from  the  so-called  "true 
diverticula,"  the  name  applied  to  the  congenital  form  in  which  all  the  coats  of 
the  intestines  are  present.  It  has  since  been  learned,  however,  that  in  the  early 
stages  of  an  acquired  diverticulum  all  the  coats  are  present,  but  that,  as  it  de- 
velops, the  muscle-fibers  become  atrophied  by  pressure  and  disappear  partially 
or  completely.  The  terms  "true"  and  "false"  are,  therefore,  no  longer  to  be 
used  synonomously  with  "congenital"  and  "acquired." 

Acquired  diverticula  may  appear  at  any  point  in  the  entire  length  of  the 
intestines,  though  more  commonly  in  the  sigmoidal  region.  They  are  rarely  if 
ever  seen  in  the  rectum.  Their  occurrence  in  the  appendix  itself  has  been 
noted  by  Kelynak,  Ribbert,  Edel,  Fischer,  Mortens,  Kelly,  and  others.  The 
diverticula  are  practically  always  multiple,  and  range  in  number  from  two  or 
three  up  to  several  hundred.  In  size  they  rarely  occur  larger  than  a  hazel  nut, 
and  many  of  them  are  microscopic.  Frequently  they  are  difficult  to  find,  since 
externally  they  may  be  completely  hidden  in  masses  of  fat,  and  when  searched 
for  from  the  inner  side  of  the  bowel  their  openings  may  be  so  small  as  to  escape 
notice.  The  diverticula  are  at  first  semiglobular  in  shape,  but  as  they  become 
larger  and  more  distended  they  assume  a  more  elongated  form,  usuallj''  with  a 
constricted  neck,  a  point  which  is  of  considerable  importance  in  the  matter  of 
later  pathologic  changes.  Most  of  the  diverticula  of  the  large  intestine  contain 
feces  which  are  retained  on  account  of  the  constricted  nature  of  the  neck.  The 
diverticula  of  the  small  intestine,  on  the  other  hand,  are,  for  the  most  part, 
empty,  due  partly  to  the  more  fluid  nature  of  the  intestinal  contents  and  partly 
to  the  fact  that  the  openings  are  less  apt  to  be  constricted.  In  the  small  intes- 
tine the  diverticula  are  almost  invariably  along  the  mesenteric  attachment, 
either  between  the  leaves  of  the  mesentery  or  just  to  one  side.  In  the  large 
intestine  they  may  occur  anywhere,  but  more  commonly  they  appear  on  some 
part  of  the  free  border.  They  are  very  apt  to  protrude  into  the  appendices 
epiploicge,  and  this  is  their  commonest  situation  in  the  large  intestine.  Those 
which  enter  the  epiploic  appendages  are  characterized  more  than  any  others  by 
having  constricted  openings.  The  walls  of  most  of  the  more  advanced  speci- 
mens contain  only  the  mucous  membrane  and  serous  coat.  Some  of  the  diver- 
ticula in  the  same  specimen  of  gut  may  contain  all  the  coats  in  their  walls;  others 
may  be  covered  with  only  the  longitudinal  layers  of  muscle-fibers,  while  others 
may  have  only  the  mucous  and  serous  coats. 

The  etiology  of  these  lesions  has  never  been  satisfactorily  elucidated.  It 
seems  fairly  evident,  though  not  incontestably  proved,  that  the  fully  developed 
condition  is  acquired  and  not  congenital,  from  the  fact  that  it  has  never  been 
discovered  in  a  child,  and  that  it  occurs  in  the  great  majority  of  cases  after  the 


GENERAL    INFLAMMATORY    PROCESSES  279 

age  of  fifty.  Most  of  the  cases  appear  in  individuals  who  have  passed  middle 
age  and  who  have  a  tendency  to  obesity.  In  a  considerable  percentage  of  the 
cases  constipation  is  an  associated  symptom.  Anatomic  study  of  the  diver- 
ticula shows  that  they  take  place  either  at  the  point  of  entrance  into  the  gut  of 
blood-vessels  or,  more  commonly,  at  the  point  of  attachment  of  an  appendix 
epiploica,  both  being  sites  of  lessened  resistance. 

The  early  investigators  differed  as  to  whether  diverticula  were  formed  by 
traction  from  without  or  by  pulsion  from  within.  Certain  forms  of  diverticula 
are  caused  obviously  by  the  traction  of  tumors  or  adhesions.  It  is  conceivable 
that  the  diverticula  of  the  small  intestine  may  be  caused  by  traction.  The 
tremendous  tractile  force  which  the  mesentery  of  the  small  intestine  exerts  on 
the  gut  during  great  distention  is  sufficiently  familiar  to  surgeons.  The  diver- 
ticula in  the  free  border  in  the  large  gut,  on  the  other  hand,  can  be  formed  in  no 
other  way  than  by  pulsion.  Apparently  the  amount  of  pulsion  necessary  to 
produce  diveritula  does  not  need  to  be  extraordinary.  Given  the  predisposing 
factor  of  innate  local  muscular  deficiency,  the  ordinary  pulsion  that  normally 
exists  in  the  bowel  is  sufficient  to  bring  about  the  result.  An  analogous  instance 
is  the  gradual  development  of  femoral  or  inguinal  hernias  in  individuals  who 
have  never  been  subjected  to  strains,  and  who,  on  account  of  an  inborn  local 
tissue  deficiency,  are  subject  to  the  formation  of  hernias  from  ordinary  intra- 
abdominal pressure. 

A  sufficient  number  of  cases  has  been  collected  from  the  operating-room 
and  from  the  pathologic  laboratory  to  show  evidence  that  probably  most  people 
having  diverticula  suffer  no  harm  from  them.  Diverticula  of  the  small  intes- 
tine appear  to  be  almost  without  danger.  In  nearly  all  cases  where  symptoms 
have  arisen  the  diverticula  have  been  situated  in  the  large  intestine  and  usually 
in  the  region  of  the  sigmoid.  The  reason  for  this  is  that  the  diverticula  of  the 
small  intestine,  unlike  those  of  the  large  intestine,  do  not  harbor  feces. 

The  mode  of  infection  of  diverticula  is  similar  to  that  of  appendicitis.  The 
diverticulum,  at  first  microscopic,  becomes  gradually  pushed  out  into  a  pouch 
with  a  constricted  opening.  This  pouch  becomes  a  receptacle  for  feces  which 
are  not  evacuated  on  account  of  the  constriction.  The  fecal  contents,  decom- 
posing and  hardened,  become  a  nidus  for  various  bacterial  flora,  and  the  con- 
cretion thus  formed,  irritating  and  ulcerating  the  mucous  lining  of  the  diver- 
ticulum, spreads  infection  by  the  lymphatics  to  the  neighboring  wall  of  the  gut 
and  to  the  peritoneum,  or  else  actually  perforates  the  wall  of  the  diverticulum 
and  causes  a  local  abscess.  Such  an  abscess  may  develop  into  a  general  peri- 
tonitis,  or  it  may  adhere  to  some  hollow  organ,  more  often  the  bladder,  and 
discharge  into  it  and  cause  a  fistula;  or  the  abscess  mass  may  absorb  spon- 
taneously. Heine  has  collected  8  cases  of  enterovesical  fistulse  which  were 
proved  to  result  from  the  adhesion  of  a  suppurating  diverticulitis  to  the  bladder. 
Numerous  other  cases  have  been  reported  since.      Undoubtedly  many  of  the 


280  GYNECOLOGY 

cases  of  gas  and  feces  in  the  bladder  have  a  similar  origin.  Hochenegge  and 
Grifiin  have  described  cases  where  carcinomata  have  developed  from  diverticula. 

The  symptoms  of  acute  diverticulitis  are  pain  in  the  left  side,  with  the  forma- 
tion of  an  inflammatory  mass  which  can  sometimes  be  felt  through  the  left 
flank,  often  in  the  left  pelvis,  by  vaginal  examination. 

Diverticulitis  is  of  special  interest  to  the  gynecologist  on  account  of  the 
location  of  the  inflammatory  process  in  or  near  the  left  pelvis.  When  the  dis- 
ease occurs  low  down  in  the  bowel  the  symptoms  and  objective  findings  from 
bimanual  examination  may  simulate  closely  a  pelvic  abscess  of  tubal  or  ovarian 
origin.  If  the  disease  is  located  higher  up  in  the  flank  it  may  be  confounded 
with  a  left-sided  appendicitis,  or  with  certain  other  inflammatory  processes  of 
the  sigmoid,  or  with  cancer.  The  diagnosis  is  important,  for  diverticuhtis  is  as 
dangerous  as  acute  appendicitis,  and  requires  prompt  surgical  interference. 

The  treatment  should  always  be  surgical,  and  is  complicated  by  the  fact  that 
the  diverticula  are  practically  always  multiple,  though  the  inflammatory  process 
may  be  confined  to  only  one  or  two  of  the  pouches.  In  very  severe  cases  the 
process  may  be  so  extensive  that  nothing  more  can  be  done  than  to  open  and 
drain  the  abscess,  from  which  a  persistent  fecal  fistula  nearly  always  results. 
When  possible,  the  best  treatment  is  to  resect  the  bowel  and  to  reunite  the 
canal,  either  by  a  lateral  or  end-to-end  anastomosis.  Sometimes  the  diverticula 
are  so  grouped  that  they  may  all  be  included  in  the  resected  segment  of  bowel. 
Frequently,  however,  diverticula  must  be  left  behind,  which  may  possibly  be- 
come inflamed  at  some  later  date  and  cause  a  repetition  of  the  acute  conditions. 
The  author  has  had  one  such  case. 


ISCfflORECTAL  ABSCESS 

Ischiorectal  abscess  is  an  acute  suppurative  process  located  in  the  peri- 
rectal tissue  about  the  lower  end  of  the  rectum  and  anus.  Patients  with 
pulmonary  tuberculosis,  and  those  who  have  had  gonorrhea  of  the  external 
genitals,  are  prone  to  this  affection,  though  it  often  appears  in  individuals 
otherwise  sound.  The  course  of  the  disease  is  characterized  by  prehminary 
malaise  and  discomfort  on  defecation,  followed  by  a  chill,  rather  high  fever, 
and  great  local  pain  and  tenderness.  A  characteristic  bulging  tumor  can  be 
seen  situated  usually  at  one  side  of  the  anus  and  occupying  the  ischiorectal 
space.  The  abscess  may  break  spontaneously  and  gradually  subside,  or,  if  not 
incised  and  drained,  it  may  spread  through  the  cellular  and  fat  tissue  in  the 
ischiorectal  fossa,  and  even  extend  to  the  opposite  side.  Such  an  abscess,  if 
neglected,  may  cause  the  death  of  the  patient  by  general  sepsis.  On  account  of 
the  tendency  of  these  infections  to  extend  upward  through  the  cellular  and  fat 
tissues,  treatment  should  consist  in  early  free  incision  and  drainage. 

Ischiorectal  abscesses  are  especially  apt  to  result  in  fistulas. 


GENERAL    INFLAMMATORY    PROCESSES 


281 


FISTULA   IN   ANO 

Anal  fistulas  may  be  the  outcome  of  previous  ischiorectal  or  perirectal 
abscesses.  The  origin  is  commonly  from  an  infected  hemorrhoid.  Neglected 
abscesses  and  those  that  rupture  spon 


\A(.?t^ 


^ 


taneously  are  usually  followed  by  a  per- 
manent fistula,  and  even  those  that  re- 
ceive early  surgical  treatment  are  apt 
to  suffer  the  same  fate. 

The  fistulous  opening  may  assume 
one  of  several  different  forms,  according 
to  the  position  of  its  outlet. 

The  fistula  is  said  to  be  complete 
when  it  opens  both  inward  toward  the 
bowel  and  outward  on  the  skin;  it  is 
said  to  be  incomplete  where  there  is  only 
one  opening,  and  this  opening  may  lead 
either  inward  or  outward,  the  other  end 
of  the  fistula  being  blind.  The  outer 
opening  is  usually  within  one  or  two 
inches  of  the  anus,  but  it  may  be  further 
away,  sometimes  even  appearing  at  or 
inside  the  perineal  outlet.  The  inside 
opening  is  in  most  cases  just  within  the 
anal  margin  between  the  upper  and 
lower  borders  of  the  sphincter  muscle. 
It  may,  however,  be  situated  above  the 
upper  border  of  the  muscle  and  com- 
municate directly  with  the  lumen  of  the 
bowel.  There  may  be  a  single  internal 
opening  which  leads  by  communicating 
channels  to  several  outlets  on  the  skin. 
In  the  severe  forms,  especially  those 
due  to  tuberculosis,  the  tissue  may  be 
greatly  undermined  with  numerous  openings  fined  with  gray  sluggish  granula- 
tions, the  surrounding  skin  being  of  a  deep  purple,  unhealthy  appearance. 
Usually  the  simple  fistulas  show  externally  only  a  small  red  papule  situated 
near  the  anus  and  containing  a  minute  opening  through  which  a  fine  probe  can 
be  passed  (Fig.  66).  The  internal  opening  may  be  microscopic,  and  is  in  most 
cases  situated  between  the  internal  and  external  sphincter. 

Anal  fistulse  are  extremely  persistent  and  do  not  often  heal  spontaneously. 
"Under  ordinary  circumstances  they  do  not  give  much  pain,  but  keep  the  patient 
in  a  state  of  annoyance  on  account  of  the  continued  shght  purulent  discharge. 


Fig.  66.  — Fistula  in  Ano. 

The   opening   of   the    fistulous    tract   usually 

appears  as  a  small  pimple  near  the  anus. 


282  GYNECOLOGY 

In  many  cases  the  external  opening  closes  more  or  less  periodically  and  causes 
a  recurrence  of  the  ischiorectal  abscess. 

The  treatment  of  fistula  in  ano  is,  as  a  rule,  surgical,  though  some  cases 
are  so  extensive  as  to  be  practicably  inoperable.  The  use  of  pastes  and  wax 
preparations  is  not  recommended  except  as  a  last  resort,  where  surgery  has 
failed. 

Surgical  procedures  are  usually  represented  by  one  of  two  methods,  one  by 
which  the  fistulous  tract  is  laid  open  and  allowed  to  heal  by  granulation,  and  the 
other  by  which  the  tract  is  entirely  extirpated  by  careful  dissection.  These 
methods  are  described  on  page  824. 

Dissection  of  the  fistula  is  recommended,  as  it  is  usually  followed  by  a 
shorter  convalescence,  and  because  it  involves  less  danger  to  the  sphincter 
muscle.  The  first  method  of  open  incision  usually  necessitates  cutting  a  por- 
tion of  the  sphincter  muscle.  If  the  internal  opening  Hes  between  the  upper  and 
lower  border  of  the  sphincter,  no  harm  is  ordinarily  done  by  dividing  the  lower 
external  half,  especially  if  the  incision  be  made  in  a  radial  direction.  If,  how- 
ever, the  internal  opening  is  situated  above  the  internal  border  of  the  sphincter, 
division  of  the  muscle  may  result  in  permanent  fecal  incontinence,  and  may 
necessitate  a  later  plastic  operation  for  repair.  By  the  dissection  method  it  is 
usually  necessary  to  do  only  slight  damage  to  the  fibers  of  the  sphincter  muscle, 
and  whatever  damage  is  done  in  the  removal  of  the  fistulous  tract  can  readily 
be  repaired  by  subcutaneous  suture  at  the  time  of  operation. 

A  third  method  is  one  devised  by  Elting,  who  removes  the  lower  end  of  the 
bowel  containing  the  fistulous  opening  in  the  manner  of  a  Whitehead  opera- 
tion for  hemorrhoids  (see  page  819).  If  the  opening  is  below  the  internal 
sphincter  and  near  the  external  orifice  this  method  is  probably  superior  to  those 
mentioned.  If,  however,  the  opening  is  situated  high,  the  dissection  method 
is  preferable. 

FISSURE   IN   ANO 

Anal  fissures  originate  as  small  cracks  in  the  surface  tissue  lining  the  folds 
of  the  anal  margins.  These  cracks  are  usually  made  by  the  passage  of  hard, 
constipated  fecal  matter,  which  produces  the  lesion  either  by  scratching  the 
membrane  or  by  overstretching  the  anus.  Fissures  made  in  this  way  usually 
heal  spontaneously,  but  occasionally  they  become  the  seats  of  chronic  ulcers 
which  persist  for  months  or  years.  The  cause  of  the  persistence  of  these  ulcers 
is  not  definitely  known,  but  it  is  thought  that  it  may  be  due  to  the  fact  that  the 
base  of  the  ulcer  becomes  involved  in  the  fibers  of  the  sphincter  muscle  and  is 
thus  prevented  from  proper  healing. 

The  fissure  bleeds  easily  and  causes  exquisite  pain  on  defecation.  For 
this  reason  the  patient  shrinks  from  having  bowel  movements  and  falls  into  a 
condition  of  chronic  constipation,  which,  in  turn,  serves  to  aggravate  the  disease. 


GENERAL    INFLAMMATORY    PROCESSES  283 

Long-continued  suffering  from  anal  fissure  may  result  in  serious  depletion 
of  the  patient's  general  health. 

The  treatment  of  fissure  is  best  carried  out  under  full  anesthesia,  when  one 
of  two  methods  can  be  used — that  of  stretching  the  sphincter  or  that  of  excis- 
ion. By  the  first  method  the  fissure  is  forcibly  and  deeply  opened,  so  that  it 
is  practically  converted  into  a  fresh  wound,  while  theoretically  (and  possibly 
practically)  the  fibers  of  the  sphincter  muscle  are  rendered  temporarily  less 
active,  so  that  the  fissure  is  given  an  opportunity  to  heal. 

A  better  and  more  surgical  procedure  is  to  make  a  clean  dissection  of  the 
fissure,  approximating  the  wound  edges  carefully  with  fine  catgut. 

It  is  possible  to  cure  a  fissure  by  patient  office  treatment.  This  consists 
in  first  cocainizing  the  fissure  and  then  applying  to  the  ulcer  silver  nitrate, 
either  in  solution  or  in  pencil  form.  The  treatment  should  be  repeated  several 
times  each  week. 

It  is  not  always  easy  to  expose  an  anal  fissure  to  view.  If  such  difficulty  is 
encountered,  the  best  method  of  examination  is  to  put  the  patient  in  Sims' 
position.  The  forefinger  inserted  in  the  vagina  can  then  easily  evert  the  anal 
canal.  If  appHcations  are  to  be  made  to  the  ulcer  it  is  advantageous  to 
place  the  patient  in  the  right  Sims'  position,  as  in  this  way  the  left  forefinger 
can  be  used  to  evert  the  anus,  leaving  the  right  hand  free  for  making  the  neces- 
sary manipulations. 

INFLAMMATORY  STRICTURE   OF   THE  RECTUM 

One  of  the  most  important  inflammatory  conditions  of  the  rectum  seen  in 
gynecologic  chnics  is  stricture.  The  lumen  of  the  rectum  may  be  constricted 
in  a  number  of  ways,  such  as  by  pressure  from  large  impacted  tumors  of  the 
pelvis,  or  from  retroperitoneal  growths,  or  from  polyps  and  malignant  growths 
of  the  rectal  tissue  itself.  Extensive  parametrial  infections  may  in  rare  in- 
stances obstruct  the  bowel.  The  term  stricture  of  the  rectum  is,  however,  com- 
monly used  to  designate  a  special  condition  of  fibrous,  cicatricial  stenosis  of 
the  lumen,  usually  occurring  within  2|  to  3  inches  from  the  anal  outlet.  The 
stricture  may  be  annular  in  form,  occupying  only  a  short  segment  of  the  bowel 
wall,  or  it  may  be  tubular,  and  extend  for  a  considerable  distance  toward  the 
sigmoid. 

The  etiology  of  the  disease  is  somewhat  obscure.  It  was  formerly  sup- 
posed that  the  majority  of  these  strictures  were  the  result  of  tertiary  syphilitic 
changes.  Modern  diagnostic  methods  have  shown  that  many  of  these  pa- 
tients do  have  syphihs,  though  not  all  of  them.  There  is  evidence  that  some 
of  the  cases  are  the  result  of  the  annular  form  of  intestinal  tuberculosis,  such  as 
occurs  elsewhere  in  the  intestinal  tract.  Some  observers  are  of  the  opinion  that 
gonorrheal  proctitis  with  ulceration  and  subsequent  cicatricial  heahng  is  im- 
portant in  the  causation.     Other  writers  practically  rule  out  gonorrhea  as  a 


284  GYNECOLOGY 

factor  in  the  disease.  Vulvovaginal  abscesses  are  said  to  open  an  avenue  of 
infection  to  the  perirectal  tissue  and  prepare  the  way  for  chronic  inflammation. 
Lynch  calls  attention  to  the  occurrence  of  cicatricial  stenoses  following  pelvic 
operations,  especially  vaginal  hysterectomies  and  end-to-end  anastomoses  of 
the  rectum,  and  assigns  the  result  to  interference  with  the  circulation  of  the 
rectal  wall.  It  is  probable  that  severe  rectal  ulceration  and  infection  of  the  peri- 
rectal tissue  from  almost  any  cause,  occurring  in  the  lower  part  of  the  rectum, 
is  capable  of  producing  a  stricture.  In  our  own  series  of  cases  syphihs  seems 
to  have  been  the  leading  cause,  though  only  in  a  few  cases  has  it  been  possible 
to  mate  a  definite  diagnosis. 

Rectal  stricture  develops  very  slowly,  patients  becoming  aware  of  trouble 
by  gradually  increasing  difficulty  in  evacuating  the  bowel.  Frequent  painful 
defecations  evoke  small  masses  of  thin  ribbon-like  stools  without  giving  the 
patient  the  sensation  of  having  emptied  the  rectum.  Mucus  and  not  infre- 
quently blood  are  passed.  On  rectal  examination  the  stricture  is  usually  found 
within  easy  reach  of  the  finger.  As  patients  do  not  seek  advice  until  symptoms 
of  occlusion  ensue,  the  opening  of  the  stricture  is  always  found  very  small, 
scarcely  admitting  the  tip  of  the  finger.  The  rectal  wall  is  densely  fibrous  and 
there  is  to  be  felt  a  firm  infiltration  in  the  pararectal  tissue.  The  cicatrix  about 
the  opening  is  slightly  elastic,  and  in  the  annular  type  can  sometimes  be  stretched 
sufficiently  to  allow  the  finger  to  slip  through.  In  passing  the  finger  through,  one 
receives  the  impression  that  the  tissue  would  easily  rupture  on  forcible  pressure. 
This  is  entirely  true,  for  even  a  gentle  attempt  at  dilatation  is  occasionally  fol- 
lowed by  a  smart  hemorrhage.  The  tubular  type  of  stricture  is  firmer  and  less 
dilatable  than  the  annular. 

Some  of  the  strictures  occur  higher  up  in  the  rectum  or  in  the  lower  sigmoid 
region,  but  they  are  much  less  common  than  those  that  form  near  the  anus. 
Many  strictures,  especially  those  of  the  syphilitic  type,  exhibit  about  the  anus 
numerous  irregular  tabs  of  skin,  with  fissures  and  rents,  commonly  called 
rhagades.  They  are  not  pathognomonic  of  stricture,  though  they  probably  are, 
for  the  most  part,  significant  of  syphihs.  The  diagnosis  of  inflammatory  stric- 
ture is  usually  a  simple  matter,  but  it  may  be  very  difficult  to  distinguish  it 
from  cancer  or  sarcoma.  Stricture,  as  a  rule,  is  attended  with  little  loss  of 
weight  or  impairment  of  health,  and  the  symptoms  are  usually  of  long  duration, 
in  contradistinction  to  mafignant  disease,  in  which  there  is  a  comparatively  short 
history  of  local  trouble,  together  with  noticeable  cachexia  and  wasting.  The 
presence  of  blood  and  pus  in  the  stools  is  characteristic  of  both  diseases.  In 
stricture  the  occluding  mass  is  smoother,  more  fibrous,  sfightly  elastic,  and 
rather  evenly  distributed  around  the  rectum.  In  malignant  disease,  especially 
cancer,  the  mass  is  irregular  and  nodular,  and  apt  to  be  more  localized  on  one 
side,  though  this  is  not  always  the  case.  In  doubtful  cases  a  Wassermann  test 
should  be  made.  If  it  is  positive,  the  balance  of  evidence  is  in  favor  of  stric- 
ture, yet  this  is  not  entirely  reliable,  as  was  seen  in  one  of  our  cases,  in  which  a 


GENERAL    INFLAMMATORY    PROCESSES  285 

positive  Wassermann  was  found  in  a  patient  who  was  discovered  at  autopsy  to 
have  rectal  cancer. 

Sometimes  a  positive  diagnosis  can  be  made  readily  by  removing  a  piece  of 
tissue  for  microscopic  examination  when  there  is  exuberant  tissue  in  the  rectal 
canal.  Often,  however,  tissue  of  diagnostic  value  is  not  easily  accessible,  and 
in  order  to  secure  a  proper  specimen  it  is  necessary  to  cut  through  the  mucous 
membrane  deep  into  the  offending  mass.  Such  a  procedure  is  not  always  ad- 
visable, but,  if  cancer  is  suspected  and  the  mass  is  operable,  the  most  radical 
measures  for  securing  an  immediate  diagnosis  are  justifiable.  Inflammatory 
stricture  is  sometimes  confused  with  intussusception  of  the  sigmoid. 

The  treatment  of  inflammatory  stricture  is  either  mechanical  or  surgical, 
for,  even  if  the  disease  is  proved  to  be  syphilitic  in  origin,  specific  treatment  is 
of  no  local  value. 

The  simplest  treatment,  and  one  that  may  be  employed  in  the  great  majority 
of  cases,  is  gradual  dilatation.  In  the  annular  type,  situated  ver}^  low,  occasional 
repeated  stret-ching  with  the  finger  gives  complete  relief.  If  the  cicatrix  is  very 
dense  or  tubular,  or  situated  beyond  the  reach  of  the  finger,  it  is  necessary  to  use 
graduated  rectal  bougies.  These  require  skilful  care,  partly  on  account  of  the 
danger  of  hemorrhage  in  stretching  the  tissue,  and  partly  because  of  the  ease 
with  which  one  of  these  instruments  may  be  forced  through  the  rectal  wall  into 
the  peritoneal  cavity,  from  a  bhnd  pouch  below  the  stricture.  It  is  best,  there- 
fore, to  use  the  instrument  through  a  proctoscope  unless  the  stricture  is  very 
low. 

Surgical  measures  for  the  relief  of  stricture  are  various.  The  simplest  and 
safest  method  for  the  narrow  constriction  is  the  use  of  Lynch's  thyrotome,  by 
which  the  constricting  tissue  is  first  seared  by  a  special  apparatus  and  then 
divided.  Much  more  radical  and  dangerous  is  the  posterior  proctotomy,  by 
which  the  posterior  rectal  wall,  including  both  sphincters,  is  boldly  divided, 
packed,  and  allowed  to  granulate. 

In  complete  obstruction  a  colostomy  may  always  be  resorted  to  with  perfect 
safety  to  the  patient.  Occasionally  it  is  advisable  to  perform  a  radical  opera- 
tion, in  which  case  the  surgical  procedure  is  the  same  as  that  for  cancer  of  the 
rectum. 

It  should  be  repeated  that,  in  the  great  majority  of  instances,  gradual  dila- 
tation is  all  that  is  necessary,  and  that  the  dangerous  surgical  measures  are  to 
be  adopted  only  as  a  last  resort. 


New  Growths 
tumors  of  the  vulva 


FIBROMA  AND   FEBROMYOMA 

True  fibromata  of  the  vulva  are  comparatively  rare  tumors,  occurring  almost 
exclusively  in  the  labia  majora.  They  do  not  often  reach  a  size  greater  than  that 
of  a  hen's  egg,  but  tumors  of  large  dimensions  have  been  reported.     They  have 


Fig.  67. — Fibroma  of  the  Vulva. 
Low  power.     On  the  surface  is  a  thin  layer  of  stratified  squamous  epithelium  showing  small, 
poorly  developed  papillae.       The  stroma  consists    of    fibrous    tissue  infiltrated  with  small  round 
cells. 

their  origin  in  the  connective  tissue  of  the  greater  hps,  and  are  usually  hard 
discrete  tumors  that  can  readily  be  shelled  out.  Some  of  them  sink  down  by 
their  weight,  drawing  the  skin  out  in  the  form  of  a  pedicle,  the  consistency  of 

286 


NEW   GROWTHS  287 

the  tumor  becoming  softer  and  more  flaccid.     This  tj^pe  is  termed  ''fibroma 
molluscum  pendulum." 

In  some  of  the  tumors  can  be  found  smooth  muscle-fibers,  while  in  others 
are  seen  small  glandular  or  cj-stic  openings  that  have  the  appearance  of  adeno- 
myomatous  tissue.  A  slender  stalk  is  sometimes  found  connecting  the  tumor 
with  the  inguinal  canal.  This  connection,  taken  with  the  histologic  appearance 
of  the  tumors,  suggests  that  the  myomatous  and  adenomyomatous  tumors  are 
probably  derived  from  the  round  ligament,  the  tumors  of  which  they  closely 
resemble. 

The  symptoms  of  fibromata  of  the  vulva  depend  on  the  size  and  position  of 
the  tumor,  and  consist  chiefly  of  discomfort  on  walking,  interference  with  coitus, 
and  a  sense  of  dragging  and  weight  if  the  growth  is  large  or  pendulous.  Thej^  are 
apt  to  undergo  marked  swelling,  with  increase  of  symptoms  before  and  during 
menstruation. 

The  diagnosis  is  usualh^  simple,  though  there  may  be  some  confusion  in 
differentiating  the  condition  from  labial  hernia,  lipoma,  or  cyst  of  Bartholin's 
gland.     The  flbromata  may  undergo  sarcomatous  change. 

The  treatment  of  flbromata  of  the  vulva  is  surgical  removal.  They  are  easily 
shelled  out  as  a  rule.  The  pendulous  form  of  tumor  may  often  be  removed  by 
simple  amputation  of  the  skin  pedicle.  Operation  is  always  indicated,  even 
when  the  tumor  is  giving  no  symptoms,  on  account  of  the  possibility  of  sarco- 
matous degeneration. 

LIPOMA 

Fatty  tumors  of  the  vulva  are  rare.  They  appear  either  in  the  labia  majora 
or  in  the  mons  veneris.  They  are  composed  of  fat  in  which  is  mingled  a  small 
amount  of  fibrous  tissue.  Occasionally  m^rxomatous  tissue  is  found,  in  which 
case  the  growth  should  be  characterized  as  a  mixed  tumor. 

It  is  said  that  the  hpomata  increase  during  pregnancy  and  diminish  during 
the  puerperium.     They  also  swell  during  menstruation. 

The  consistency  of  lipomata  of  the  labium  is  soft  and  almost  fluctuant,  so 
that  it  is  sometimes  with  difficulty  differentiated  from  a  cyst. 

The  treatment  is  surgical  removal. 

A  rare  tumor  of  the  vulva  is  called  "adenoma  hidradenoides  vulvae" ;  the  tumor  is  benign  and 
shows  a  growth  of  glandular  tubes  lying  close  together  with  sUght  connective-tissue  stroma. 
The  glands  are  Hned  with  regular  cyUndric  epithelium.  The  structure  shows  the  histologic 
characteristics  of  the  sweat-glands;  hence  the  name  (Stern). 

CARCINOMA   OF  VULVA 

Cancer  of  the  vulva  is  comparatively  uncommon,  and  does  not  usually  appear 
until  after  middle  life.  It  takes  its  origin  chiefly  from  the  urethral  orifice,  from  the 
clitoris,  and  from  the  sulcus  between  the  greater  and  lesser  lips,  rarely  from 
Bartholin's  glands.     In  advanced  cases  the  origin  cannot  usually  be  distinguished. 


288 


GYNECOLOGY 


The  great  majority  of  cancers  of  the  vulva  are  of  the  squamous  epithelial 
type,  but  growths  from  Bartholin's  glands  are  adenocarcinomatous,  while  a 
rare  form  of  melanotic  carcinoma  has  been  described.  It  is  possible  for  cancer 
of  the  uterus  to  become  secondarily  implanted  on  the  vulva,  in  which  case  the 
growth  has  the  histologic  structure  of  the  primary  tumor.     As  a  rule,  the  growth 


CaT:\CtP  -' 


V\(.f?GrA\)es- 


FiG.  68.  —Early  Cancer  of  the  Vulva,  with  Ixfiltr-'^.tion  of  the  Tissues  at  the  Posterior 

Commissure  and  Beginning  Ulceration. 


appears  on  one  side,  and  is  at  first  irregular  and  nodular,  without  ulceration,  and 
is  surrounded  by  a  more  or  less  krau^otic  tissue,  from  which  it  seems  to  spring. 

On  account  of  the  rich  lymphatic  circulation  of  the  vulva,  cancer  in  this 
location  is  extremely  malignant,  and  metastasizes  early  to  the  inguinal  tym'ph- 
glands,  and  thence  to  the  glands  of  the  iliac  system. 

The  disease  in  the  early  stages  is  not  painful,  and  does  not  at  this  time  often 
come  to  the  notice  of  the  physician,  symptoms  ensuing  when  the  tumor  becomes 


NEW    GROWTHS 


289 


ulcerated  or  when  the  inguinal  glands  become  infected.  Locally  the  disease 
gives  rise  to  itching  and  burning  and  a  bloody  foul  secretion  bathing  the  external 
parts.  The  involvement  of  the  inguinal  glands  may  be  very  extensive  and 
exceed  in  severity  the  processes  of  the  primary  growth.  The  pain  in  the  later 
stages  of  the  disease  is  excruciating,  enhanced  as  it  often  is  by  thrombotic  ex- 
tension into  the  veins  of  the  leg. 


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Fig.  69. — Epithelioma  of  the  Vulva. 
High  power.     This  section  shows  the  surface  epithelium,  which  is  not  ulcerated,  and  the  finger- 
like projections  of  the  growth  extending  into  the  deeper  parts  of  the  stroma  of  the  ^'ulva.     There  is 
no  basement-membrane  between  the  cells  of  the  growth  and  those  of  the  stroma.     The  carcinoma 
cells  are  irregular  in  shape  and  vary  in  size.     Very  few  mitotic  figures  are  seen  in  this  section. 


The  diagnosis  of  cancer  of  the  vulva  is  not  always  easy  to  make  by  inspec- 
tion. In  the  early  nodular  stage,  with  beginning  ulceration,  it  maj^  closely 
resemble  a  primary  syphilitic  lesion,  while  in  the  later  ulcerative  stages  it  may 
be  impossible  to  distinguish  it  from  esthiomene.  The  latter  diagnosis  is  especi- 
ally difficult,  for  cancer  of  one  side  of  the  vulva  is  often  in  time  communicated 
to  the  other  side  by  contact  infection,  so  that  sj^mmetric  ulcerations  exactly 
simulating  esthiomene  are  frequently  seen.     Elephantiasis,  tuberculosis,  and 

19 


290 


GYNECOLOGY 


even  condylomata  acuminata  are  sometimes  mistaken  for  cancer.  In  all  cases 
where  there  is  the  slightest  doubt  of  the  diagnosis  a  specimen  should  be  removed 
from  the  growth  for  microscopic  examination. 

The  treatment  of  cancer  of  the  vulva  is  immediate  and  radical  operation  if 
the  case  when  seen  is  operable.  The  operation  consists  in  an  extensive  vulvec- 
tomy and  dissection  of  the  inguinal  lymph-glands  of  both  sides.  Most  of  these 
cases  come  to  operation  late,  and  on  account  of  the  tendency  to  early  metastases 
the  prognosis  is,  consequently,  unfavorable  as  a  rule.  If  the  case  is  inoperable  the 
best  hope  of  relief  is  from  radium. 

The  most  valuable  recent  work  on  the  subject  of  cancer  of  the  vulva  is  that  embodied  in  a 
report  by  Taussig  of  15  cases  personally  observed.  The  following  are  the  conclusions  reached 
by  Taussig: 

Cancer  of  the  vulva  is  very  definitely  a  disease  of  old  age,  the  majority  of  cases  occurring 
after  the  age  of  sixty.    The  question  of  age  depends,  however,  on  the  etiologic  factor-s  in  the 


Fig.  70. — Extensive  Cancer  of  the  Vulva  Originating  in  Condylomata  Acuminata  (after 

Taussig). 


case  and  under  certain  conditions  the  disease  may  appear  in  young  women.  Taussig's  obsetva- 
tions  regarding  the  etiology  are  especially  valuable.  Thus  in  his  series  of  cases  he  found  defi- 
nite proof  that  the  cancerous  growth  may  originate  from  the  following  conditions:  trauma, 
syphihs,  condylomata  acuminata,  kraurosis,  leukoplakia,  and  Paget's  disease.  The  most  com- 
mon predisposing  cause  is  found  in  the  atrophic  kraurotic  processes  that  characterize  the  vulva 


NEW    GROWTHS 


291 


in  old  age.  Hence  the  greater  incidence  of  the  disease  at  that  time.  On  the  other  hand,  it 
may  develop  from  syphilis  or  condylomata  acuminata,  so  that  it  may  appear  early.  Taussig's 
youngest  cases  were  twenty-seven  and  thirty-three.  The  disease  is  unusually  malignant 
when  it  occurs  in  younger  women. 

Taussig  suggests  that  the  cessation  of  the.  ovarian  secretion  after  the  menopause  may  be  a 
predisposing  element  in  the  development  of  vulvar  cancer,  for  in  two  of  his  comparatively 
young  cases  (i.  e.,  under  forty-five)  a  previous  operation  involving  the  removal  of  the  ovaries 
had  been  performed. 

Previous  pregnancies  are  not  a  factor  in  the  etiology,  for  the  disease  appears  with  about 
equal  frequency  in  those  who  have  not  borne  children. 


FiG.  71. — Cancer  of  Clitoris  with  Metastasis  in  Groin  (after  Taussig). 


Cancers  that  originate  from  a  kraurotic  vulva  are  somewhat  more  benign  in  their  course. 
They  have  a  tendency  to  eversion  rather  than  inversion,  suggesting  that  the  tissues  in  the 
kraurotic  cases  possess  a  greater  imperviousness  to  the  progress  of  the  disease. 

The  lymph-glands  are  involved  even  in  the  earliest  stages  of  the  disease.  "Even  after 
radical  removal  of  the  lymph-glands  with  the  vulvar  mass  the  chance  for  a  reappearance  of  the 
cancer  in  the  glandular  system  is  three  times  greater  than  in  the  local  recurrence." 

The  site  of  the  original  tumor  was  in  order  of  frequency  as  follows:  labial  fold,  clitoris, 
Bartholin's  gland,  peri-urethral  region.  When  the  disease  is  locally  far  advanced  it  may  be 
impossible  to  distinguish  the  point  of  origin.  The  cancers  that  developed  from  the  labial 
folds  were  more  scirrhous  in  type  and  slower  in  growth.  Those  that  sprang  from  the  clitoris  or 
vestibule  were  of  a  softer  and  much  more  malignant  nature. 

Taussig  has  adopted  a  special  technic  in  operating  on  cancer  of  the  vulva  which  will  be 
found  explained  in  detail  in  Part  III  of  this  book.  In  general  his  method  comprises  first  a 
complete  dissection  of  the  inguinal  regions  by  the  Basset  technic.     At  the  end  of  about  two 


292 


GYNECOLOGY 


Fig.  72. — Cancer  of  Vulva  Originating  from  Kraurotic  Labium. 

weeks  the  tumor  mass  is  removed  by  cautery,  no  attempt  being  made  to  cover  in  the  wound 
by  plastic  maneuvers. 

SARCOMA   OF   VULVA 

Sarcoma  of  the  vulva  is  even  less  common  than  carcinoma.  It  presents  no 
definite  characterizing  features  clinically,  appearing  at  first  as  a  circumscribed 
hard  oval  tumor,  not  to  be  distinguished  from  fibroma  excepting  by  its  more 
rapid  growth.  Later  it  may  infiltrate  the  surrounding  tissues  and,  becoming 
ulcerated,  resemble  carcinoma  or  esthiomene.  An  absolute  diagnosis  can  only 
be  made  by  the  microscope,  which  reveals  various  malignant  types  in -different 
tumors,  such  as  spindle-  and  round-cell  forms,  myxosarcoma,  and  perithehoma. 
Many  of  the  reported  sarcomata  of  the  vulva  are  melanotic,  and  doubtless  orig- 
inate in  pigmented  nevi. 

The  treatment  of  sarcoma  of  the  vulva  is,  like  that  of  carcinoma,  radical 
surgery. 

Rare  Tumors  of  the  Vulva. — A  few  cases  have  been  reported  in  the  literature 
of  neuroma,  enchondroma,  myxoma,  osteoma,  teratoma,  and  echinococcus  cyst 
of  the  vulva. 

Cysts  of  Bartholin's  gland  have  been  described  on  page  186.  A  few  cases  of 
carcinoma  developing  from  this  gland  have  been  reported. 

Hydrocele  muUebris  is  a  cyst  which  sometimes  extends  from  the  inguinal 
canal  into  one  of  the  labia  majora.  It  represents  a  cystic  condition  of  the  canal 
of  Nuck. 


NEW    GROWTHS  293 


VARICOCELE 


Varicocele  of  the  vulva  occurs  almost  exclusively  as  a  result  of  pregnancy. 
The  veins  may  become  greatly  dilated  and  form  an  irregular  tumor,  usually  on 
one  side  of  the  vulva.  After  delivery  the  distention  either  subsides  completely 
or  leaves  a  few  isolated  veins  permanently  dilated.  These  are  usually  seen  in 
the  neighborhood  of  the  clitoris. 

Varicocele  of  the  vulva,  if  extensive,  may  cause  discomforting  pain  and  be  a 
source  of  danger  on  account  of  the  possibility  of  rupture. 

Surgical  treatment  is  rarely  indicated  except  when  permanent  varices  of 
considerable  size  are  left  after  childbirth.  The  best  treatment  is  rest  in  bed,  with 
the  use  of  the  knee-chest  position  two  or  three  times  daily. 

Rupture  may  occur  spontaneously  or  after  some  violent  effort,  or  from  trauma. 

Rupture  may  result  in  a  large  hematoma,  or  if  the  skin  is  broken,  in  a  serious  or 

even  fatal  hemorrhage. 

URETHRAL   CARUNCLE  ■ 

The  urethral  caruncle  (sometimes  termed  "papillary  angioma")  is  essentially 
a  mucous  polyp  of  the  vestibule.  In  its  most  common  form  it  appears  as  a  small 
polypoid  growth,  either  with  a  broad  base  or  with  a  fine  slender  pedicle  growing 
from  the  meatus.  It  is  intensely  red  in  color  and  often  exquisitely  tender.  In 
exceptional  cases  the  polypoid  growth  is  multiple,  extending  over  a  considerable 
area  of  the  vestibule,  so  that  it  has  a  papillary  appearance  often  suggesting  car- 
cinoma. 

Microscopically,  the  true  caruncle  is  clothed  with  a  squamous  epithelium. 
The  underlying  connective  tissue  is  usually  infiltrated  with  round  cells.  The 
epithelial  covering  sends  down  off-shoots  into  the  deeper  tissues  which,  on  cross- 
section,  present  an  appearance  closely  resembling  squamous  cell  carcinoma. 
Gebhard  describes  tubular  glands  that  pervade  these  polyps,  the  lining  epithelium 
of  which  exhibits  extraordinary  changes  that  range  from  squamous  epithelium, 
like  that  of  the  vestibule,  to  a  high  cylindric  type  with  basal  membrane. 

Clinically,  the  urethral  caruncles  may  be  very  troublesome  affairs.  They  are 
especially  apt  to  occur  in  elderly  women,  though  not  confined  to  that  age.  Their 
importance  hes  chiefly  in  the  intense  pain  which  they  often  cause  during  urina- 
tion or  coitus. 

The  diagnosis  is  usually  simple,  though  they  are  sometimes  not  easily  dis- 
tinguished from  a  prolapsed  urethral  mucous  membrane  except  by  micro- 
scopic examination  of  the  tissue.  The  true  caruncle  is  covered  with  squamous 
epithelium  like  that  of  the  vestibule,  while  prolapse  of  the  urethral  mucous  mem- 
brane is  covered  with  the  modified  epithelium  characteristic  ofthe  urinary  tract. 

The  extensive  caruncular  growths  that  spread  out  over  the  vestibule  may 
easily  be  regarded  as  cancerous  growths.  The  diagnosis  should  be  made  by 
microscopic  examination  of  an  excised  specimen.  The  microscopic  resemblance 
to  cancer  should  be  borne  in  mind. 

The  treatment  of  simple  urethral  caruncle  is  removal  under  cocain,  if  possible. 
Sometimes,  however,  the  growth  is  so  tender  that  the  patient  will  not  even  allow 


294 


GYNECOLOGY 


the  application  of  cocain,  so  that  complete  anesthesia  is  necessitated.      The 
caruncle  may  also  be  removed  by  fulguration. 

It  is  advisable  not  to  attempt  the  removal  of  the  extensive  multiple  caruncles 
by  surgical  dissection,  for  they  usually  recur.  The  best  treatment  is  by  repeated 
applications  of  the  high-frequency  current,  by  which  means  they  are  more  easily 
kept  under  control,  though  not  alwaj^s  permanently  cured. 

URETHRA 

Prolapse  of  the  urethral  mucous  membrane  is  most  commonly  an  affection 
of  old  age,  though  it  may  appear  in  infants  or  in  girls  before  the  age  of  puberty. 

Prolapse  of  the  urethra  in  the  adult  is  usually  a  result  of  senile  atrophy,  and 
is  apparently  due  to  traction  of  the  shrinking  skin  of  the  vestibule  on  the  loose 
mucous  membrane  of  the  urethra.     In  its  simplest  and  most  common  form  it 


Fig.  73. — Prolapsed  Urethr.\l  Mucous  Membrane. 
Low  power.     The  crypts  in  the  mucous  membrane  are  seen  in  cross-section.     The  epithelium  is 
like  that  of  the  urethra.     This  distinguishes  the  condition  from  the  true  urethral  caruncle,  which  is 
covered  with  simple  squamous  epithelium.     The  stroma  contains  manj'  blood-vessels  filled  with  cor- 
puscles and  is  infiltrated  with  leukocytes. 


appears  as  an  eversion  or  ectropion  of  the  urethral  mucous  membrane,  which 
either  in  part  or  in  its  entire  circumference  rolls  out  into  view.     The  affection 


NEW    GROWTHS  295 

is  often  mistaken  for  caruncle.  In  the  simple  form  it  ordinarily  gives  no  dis- 
comfort, but  under  certain  conditions  it  may  be  the  source  of  serious  trouble. 
Congestion  and  constriction  of  the  blood-vessels  may  produce  a  change  similar 
to  that  seen  in  hemorrhoids,  with  thrombosis,  swelling,  and  bleeding.  In  extreme 
cases  there  may  be  gangrene  and  sloughing  of  the  protruding  membrane. 

Prolapse  of  the  urethra  in  which  thrombosis  has  occurred  may  simulate  cancer 
somewhat  in  appearance.  Treatment  of  urethral  prolapse  depends  on  the 
severity  of  the  case.  Mild  conditions  which  give  no  symptoms  need  no  special 
treatment.  If  congestion,  thrombosis,  or  gangrene  appear,  the  best  treatment  is 
surgical  removal,  the  prolapsed  and  swollen  portion  of  the  membrane  being 
removed  in  the  manner  of  Whitehead's  operation  for  hemorrhoids  and  the 
wound  edges  sewed  with  fine  catgut. 

Prolapse  of  the  urethra  in  children,  according  to  Kelly,  may-  date  back  to  the 
nursing  period  of  life,  and  may  involve  either  a  part  or  most  of  the  urethral 
mucous  membrane.  There  is  pain  on  urination,  reddening  and  swelling,  and 
often  bleeding.  Kelly  states  that  the  disease  either  comes  on  slowly  or  may 
develop  suddenly  from  traumatic  causes  like  rape,  violent  coughing,  long-stand- 
ing diarrhea,  local  injuries,  etc. 

The  treatment  is  surgical  removal. 

TUMORS    OF   THE   CLITORIS 

Tumors  of  the  clitoris  are  comparatively  infrequent.  In  cases  of  pseudo- 
hermaphroditism the  clitoris  is  often  very  much  enlarged,  resembling  a  small 


\ 


Fig.  74. — Hypertrophy  of  the  Clitoris. 
Low  power.     Cross-section  of  the  clitoris.     Around  the  edge  is  the  stratified  squamous  epithe- 
lium.    Beneath  this  and  scattered  through  the  stroma  are  dilated  blood-  and  lymph-spaces.     The 
hypertrophy  in  the  stroma  consists  of  an  increase  in  connective  tissue  and  the  corpora  cavernosa 
cannot  be  made  out  distinctly. 

penis,  but  not  perforated  by  a  urethra.     It  is  sometimes  advisable  to  excise  the 
organ  in  such  cases,  expecially  if  it  is  a  source  of  irritation.     An  acquired  hyper- 


296  GYNECOLOGY 

trophy  of  the  chtoris  is  occasionally  seen,  which  is  thought  to  be  caused  by  mas- 
turbation. There  is  doubt,  however,  whether  masturbation  produces  hyper- 
trophy or  whether  the  hypertrophy  is  not  rather  the  primary  condition,  causing 
masturbation  by  irritative  influence.  Certain  it  is  that  masturbation  sometimes 
results  in  atrophy  of-  the  chtoris  (Kiistner).  Hypertrophy,  if  it  becomes  trouble- 
some, requires  a  clitoridectomy. 

Removal  of  a  normal  clitoris  for  masturbation  is  of  questionable  value. 


Fig.  75. — Hypertrophy  of  the  Clitoris. 
High  power.    Along  the  edge  of  the  section  is  the  squamous  epithehum.     Many  blood-vessels  full 
of  corpuscles  are  seen  throughout  the  stroma,  and  to  the  right  are  several  dilated  lymph-spaces. 
The  darker  areas  are  small  bundles  and  muscle-fibers  scattered  through  the  stroma. 

Carcinoma  of  the  clitoris  is  occasionally  met  with.  It  follows  the  course 
and  demands  the  surgical  treatment  of  any  cancer  of  the  vulva,  namely,  com- 
plete vulvectomy  and  dissection  of  the  inguinal  regions. 

TUMORS   OF   THE   VAGINA 

SARCOMA   OF   THE   VAGINA 

Sarcomata  of  the  vagina  are  comparatively  rare  tumors.  Two  forms  are  to 
be  distinguished:  (1)  Those  which  occur  in  children  and  (2)  those  which  appear 
in  adult  life. 


NEW   GROWTHS  297 

The  sarcomata  of  children  are  usually  congenital,  and  are  thought  (Wilms)  to 
have  their  origin  in  off-shoots  of  the  mesoderm  which  become  detached  during 
the  early  growth  of  the  Wolffian  duct.  Histologically,  these  tumors  are  primarily 
composed  of  myxomatous  tissue,  connective  tissue,  and  both  smooth  and  stri- 
ated muscle-fibers,  with  sarcomatous  metaplasia.  They  are,  therefore,  not  true 
sarcomata  in  the  strictest  sense  of  the  word,  but  are  mixed  tumors  related  to 
the  teratoid  group.  They  usually  spring  from  the  anterior  wall  of  the  vagina, 
occasionally  from  the  posterior,  and  have  a  characteristic  polypoid  or  grape-like 
form  protruding  from  the  lips  of  the  vulva.  The  sarcomatous  polyps  soon  be- 
come necrotic  and  the  vagina  is  filled  with  a  septic,  sloughing  mass.  The  disease 
infiltrates  the  deeper  layers  of  the  vagina,  soon  involves  the  cervix  and  bladder, 
extends  to  the  uterus  and  vulva,  infiltrates  the  pelvic  connective  tissue,  and 
metastasizes  in  the  regional  lymph-glands.  When  the  growth  begins  on  the 
posterior  wall  of  the  vagina  it  has  little  tendency  to  involve  the  rectum.  The 
disease  is  nearly  always  fatal,  only  a  very  small  number  of  cases  having  been 
cured.  The  only  hope  of  a  cure  is  from  a  very  early  diagnosis  and  a  radical 
extirpation  of  the  uterus  and  vagina. 

Sarcoma  of  the  vagina  in  the  adult  follows  the  usual  form  of  sarcoma  found  in 
the  rest  of  the  body.  Cases  of  melanotic,  myxomatous,  telangiectatic,  and 
giant-cell  type  have  all  been  reported.  These  tumors  appear  either  as  nodular 
or  infiltrating  growths  from  any  part  of  the  vagina,  and  involve  the  entire 
vaginal  canal  in  a  hard,  resisting  mass.  The  disease  is  usually  hopeless.  If  an 
early  diagnosis  can  be  made,  the  treatment  is  complete  removal  of  the  uterus  and 
vagina. 

CARCINOMA   OF  VAGINA 

Primary  cancer  of  the  vagina  is  somewhat  uncommon.  These  growths  usu- 
alty  originate  in  the  squamous  epithelium  of  the  vagina,  but  occasionally  are 
adenocarcinomatous  in  type,  in  which  case  it  is  supposed  that  they  spring  from 
congenital  cysts  or  gland  inclusions  of  the  vaginal  mucous  membrane. 

Cancer  of  the  vagina  secondary  to  cancer  of  the  uterus  is  frequent,  and  doubt- 
less many  of  the  cases  reported  as  primary  are,  in  reality,  of  this  kind. 

Primary  cancer  of  the  vagina  usually  springs  from  the  posterior  wall.  On 
account  of  this  location  it  has  been  claimed  that  the  disease  is  the  result  of 
trauma  such  as  would  result  from  the  use  of  pessaries.  It  is  doubtful  if  pessaries 
do  more  than  encourage  the  development  of  a  tissue  already  predisposed  to 
cancer. 

The  growth  has  at  first  a  circular  circumscribed  appearance  with  somewhat 
raised  indurated  periphery.  The  original  area  gradually  spreads,  infiltrating 
the  paravaginal  connective  tissue,  until  it  involves  the  entire  vaginal  canal. 
Ulceration  and  bleeding  take  place  early,  and  the  symptoms  are  the  same  as 
those  of  cancer  of  the  cervix. 

The  diagnosis  of  primary  cancer  of  the  vagina  is  usually  not  difficult  unless 


298 


GYNECOLOGY 


the  disease  has  so  involved  the  cervix  that  the  original  seat  of  the  disease  cannot 
be  distinguished. 

The  prognosis  of  vaginal  cancer  is  very  bad,  but  extirpation  is  possible  if  an 
early  diagnosis  can  be  made.  The  method  of  operation  depends  on  the  original 
seat  of  the  disease.  If  it  is  located  high  in  the  vagina  the  best  operation  is 
abdominal  extirpation  of  the  uterus  and  vagina  by  the  Wertheim  extended 
method.     If  the  cancer  is  situated  near  the  introitus  the  operation  should  be 


Fig.  76. — Squamous  Carcinoma  of  the  Vaginal  Wall. 
Low  power.     The  growth  is  seen  invading  the  stroma  of  the  vaginal  wall.     At  its  upper  end  it  has 
lost  the  typical  layer  of  basal  cells  and  the  basement-membrane.     The  cells  are  large,  the  nuclei  vary 
greatly  in  size.     The  stroma  above  the  growth  is  infiltrated  with  leukocytes,  an  inflammatory  reaction 
often  found  with  carcinoma. 

from  below,  and  be  completed  either  from  below  or  be  combined  with  abdominal 
extirpation. 

In  inoperable  cases  radium  sometimes  proves  to  be  valuable  as  a  palliative 
measure. 

When  the  disease  has  extended  into  the  rectum  the  only  hope  of  a  cure  is  a 
total  extirpation  of  the  uterus,  vagina,  and  rectum.  This  necessitates  the  estab- 
lishment of  an  artificial  anus. 


NEW   GROWTHS 


299 


Secondary  cancer  of  the  vagina  is  very  common,  especially  as  a  manifesta- 
tion of  advanced  cancer  of  the  cervix.  Both  everting  and  inverting  carcinoma 
of  the  cervix  tend  in  time  to  involve  the  paravaginal  connective  tissue,  especi- 
ally in  the  anterior  wall  between  the  vagina  and  bladder.  It  is  for  this  reason 
that  it  is  important,  in  performing  a  radical  operation  for  cancer  of  the  cervix, 
to  remove  as  much  of  the  vagina  as  possible. 


-'^      \    fee. 


•«»♦« 4^ ■<*.,.  -^&  "     ^     a    h^^»J''^i 


Fig.  77. — Squamous  Carcinoma  of  the  Vaginal  Wall. 

High  power.     Near  the  center  is  a  giant  carcinoma   cell   containing  many  nuclei.     Just  above 

it  to  the  left  is  a  mitotic  figure.     This  is  taken  from  the  small  area  in  the  left  side  of  Fig.  70. 

Cancer  of  the  body  of  the  uterus  does  not  directly  involve  the  vagina,  but 
may  infect  it  by  metastatic  seed  implantation. 

The  vagina  may  also  be  the  seat  of  chorio-epithelioma.  Rarely  the  tumor  is 
primary  in  the  vagina;  it  usually  represents  a  metastasis  from  a  primary  growth 
in  the  uterus. 


VAGINAL    CYSTS 


Small  cysts  of  the  vaginal  wall  are  comparatively  common.  They  vary  in 
size  from  that  of  a  hazelnut  to  an  Enghsh  walnut,  though  rarely  they  may  become 
very  large,  extending  upward  into  the  broad  hgament.     They  usually  appear  on 


300 


GYNECOLOGY 


the  anterior  wall  and  may  be  single  or  multiple.  They  occur  at  any  age,  even 
in  childhood,  and  first  make  themselves  evident  by  protruding  from  the  introitus. 
The  etiology  of  these  cysts  is  somewhat  varied.  Undoubtedly  many  of  them 
arise  from  gland-inclusions  formed  by  infoldings  of  the  mucous  membrane  in 
fetal  life.  This  accounts  for  the  smaller  cysts.  Some  of  the  larger  ones  probably 
have  their  origin  in  Gartner's  duct.  In  cases  of  narrow  or  unilateral  vagina 
it  is  thought  that  cysts  may  arise  from  glandular  structures  representing  the 
undeveloped  Miiller's  duct  of  the  other  side.     Multiple  cysts  of  the  vagina  are 


Fig.  78. — Normal  Vaginal  Wall. 
Low  power.     On  the  surface  is  a  covering  of  well-developed  stratified  squamous  epithelium. 
This  lies  on  connective  tissue  through  which  are  scattered  bundles  of  smooth  muscle-fibers  and  many 
blood-vessels.  . 

less  common  than  the  single  cysts.  If  they  occur  in  a  line  they  are  supposed  to 
originate  from  Gartner's  duct,  while  if  they  are  irregularly  placed  they  prob- 
ably develop  from  vaginal  gland  inclusions. 

The  small  vaginal  cysts  do  not  ordinarily  give  subjective  symptoms,  but  in 
married  women  they  often  interfere  with  coitus  and  sometimes  with  childbirth. 

The  diagnosis  of  vaginal  cysts  is  extremely  easy,  there  being  little  else  with 
which  they  could  be  confused.  The  cysts  have  a  thin  wall  lined  with  a  single 
layer  of  epithelium  and  contain  a  clear  serous  fluid. 


NEW   GROWTHS 


301 


The  treatment  is  operative.  The  smaller  cysts  can  usually  be  shelled  out 
with  comparative  ease,  though  care  must  be  exercised  not  to  injure  the  bladder. 
The  larger  cysts,  especially  those  that  extend  inward  and  upward  between  the 
leaves  of  the  broad  hgament,  may  present  serious  technical  difficulties.  The 
methods  of  removal  must  be  determined  by  the  exigencies  of  the  individual  case. 

Cysts  of  the  anterior  wall  sometimes  communicate  with  the  urethra,  in  which 
case  they  are  not  true  cysts,  but  are  rather  diverticula  of  the  urethral  canal- 
It  is  probable  that  most  cysts  of  this  type  originate  as  periurethral  abscesses. 


Fig.  79 — Wall  of  a  Vaginal  Cyst. 
Low  power.     At  the  bottom  is  the  layer  of  squamous  epithelium  which  lines  the  vagina.     Above 
this  is  the  connective-  and  muscle-tissue  wall  of  the  vagina  and  at  the  top  a  layer  of  cuboidal  epithe- 
lium which  lines  the  cyst.     This  is  characteristic  of  a  cyst  of  Gartner's  duct. 


In  the  lower  part  of  the  vagina,  near  the  introitus,  cysts  may  arise  from  the 
inclusion  of  small  areas  of  epithehum  following  healing  from  lacerations  or  opera- 
tions for  repair  of  the  perineum  where  there  has  been  an  incomplete  denudation 
of  the  mucous  membrane.  These  cysts  might  properly  be  included  under  the 
term  "perineal  cysts,"  but,  as  they  often  result  from  a  high  denudation,  they 
may  be  situated  well  up  in  the  vaginal  canal,  usually  on  one  side. 

The  contents  of  these  cysts  is  a  yellowish,  semifluid,  sebaceous  material,  and 
represents  the  activity  of  the  included  epithehum  with  retention  of  the  secretion. 


302 


GYNECOLOGY 


They  are  usually  about  the  size  of  a  pea,  though  they  may  attain  that  of  a  hazel- 
nut. As  a  rule  they  are  not  painful,  but  sometimes  cause  a  disagreeable  irrita- 
tion at  the  introitus,  which  may  be  so  severe  as  to  cause  dyspareunia  or  even 
serious  vaginismus.  The  treatment  is  removal  by  dissection  if  they  give  symp- 
toms. 

A  special  form  of  vaginal  cyst  and  one  which  may  cause  serious  surgical 
compHcations  is  that  which  results  from  a  bhnd  secondary  vagina.  There  are 
two  types  of  defective  development  which  may  cause  vaginal  cysts  of  this  kind. 
In  one  there  exists  a  rudimentary  uterus  and  a  rudimentary  blind  vagina,  the 


Fig.  80. — Vaginal  Cyst  Due  to  Blind  Supernumerary  Vagina. 
In  this  case  both  horns  and  cervices  are  fully  developed.     There  are  two  vaginas,  but  one  has 
no  outlet.     The  blind  vagina  is  converted  into  a  cyst  which  becomes  filled  with  products  of  men- 
struation from  the  corresponding  uterine  horn. 


canals  of  which  do  not  communicate  (Fig.  80).  In  these  cases  the  cervix  of  the 
rudimentary  uterus  becomes  fused  with  that  of  the  well-developed  organ.  Secre- 
tions accumulate  in  the  blind  vaginal  sac  and  produce  a  cyst,  as  shown  in  the 
drawing. 

In  another  type  there  exists  a  double  uterus,  double  cervLx,  and  double 
vagina,  but  the  vagina  of  one  side'  is  without  an  external  opening.  In  this  case 
the  blind  vagina  becomes  filled  with  menstrual  products  in  the  form  of  a  charac- 
teristic chocolate  colored  fluid.  Sometimes  the  pressure  may  be  so  great  as  to 
break  an  opening  through  into  the  normal  vagina.  When  this  occurs  the  con- 
tents of  the  sac  become  infected  and  the  blind  vagina  is  converted  into  a  reser- 
voir of  foul  pus  which  discharges  constantly  or  periodically  into  the  normal 
vagina. 


NEW    GROWTHS 


303 


Fig.  81. — Vaginal  Cyst  Due  to  Blind  Superntjmerary  Vagina. 

On  one  side  there  is  a  fully  developed  uterine  horn,  cervix,  and  vagina.  On  the  other  is  a  rudi- 
mentary uterine  horn,  the  cer-\-ix  being  fused  and  without  a  canal.  Corresponding  to  the  rudimen- 
tarj^  horn  is  an  undeveloped  vagina  -nithout  an  outlet.  Secretions  have  converted  the  vagina  into 
a  cyst. 


Fig.  82. — Vaginal  Cyst  Due  to  Blind  Supernumerahy  Vagina. 

Drawing  illustrates  author's  case  described  in  the  text.  One  uterine  horn  had  been  amputated 
by  a  previous  operator.  A  cj'st  which  had  formed  in  a  blind  vagina  had  forced  an  opening  into  the 
cervical  canal.  The  contents  of  the  vaginal  sac  had  become  infected  so  that  the  sac  fed  by  the  uterine 
secretions  became  a  reservoir  of  foul  pus. 


304 


GYNECOLOGY 


In  a  case  seen  by  the  writer  one  of  the  horns  of  a  double  uterus  had  been  removed  several 
years  before  by  another  operator.  When  the  patient  presented  herself  for  examination  there 
was  found  an  immense  pus  sac  which  was  discharging  through  the  cervix  of  the  remaining  uterus. 
After  an  unsuccessful  attempt  to  rectify  the  trouble  by  draining  the  abscess  through  the  vagina 
the  patient  was  finally  cured  by  performing  a  complete  hysterectomy  and  establishing  full 
drainage  for  the  abscess  sac  through  both  vagina  and  abdominal  wall.  After  a  time  the 
vaginal  sac  dried  up,  the  walls  evidently  healed  together  by  plastic  adhesions,  and  the  patient 
got  well.  In  this  case  the  septum  between  the  two  vaginae  had  become  the  seat  of  a  great 
plexus  of  vaginal  veins,  so  that  an  attempt  to  remove  the  septum  and  to  convert  the  two 
vagina  into  a  single  canal  could  not  be  carried  out.  Otherwise  this  procedure  would  theoret- 
ically have  been  preferable  to  the  operation  of  hysterectomy,  as  the  patient  was  a  young 
woman. 

Fibromyomata  and  myomata  of  the  vagina  are  "very  rare  tumors,  less  than  200 
having  been  reported.  They  arise  from  the  smooth  muscle-tissue  of  the  vaginal 
wall.     They  do  not  attain  a  large  size,  and  are  usually  polypoid  in  their  develop- 


FiG.  83. — Vaginal  Cyst  Wall. 
High  power.     At  the  top  is  the  lining  of  the  cyst,  consisting  of  a  single  layer  of  low  cells.    The 
rest  of  the  tissue  consists  of  the  loose  connective  tissue  of  the  vaginal  wall  with  several  veins  in  it. 
This  is  a  cyst  of  Gartner's  duct. 


ment.  They  have  a  predilection  for  the  posterior  wall  of  the  vagina.  They  are 
especially  prone  to  necrosis,  infection,  and  sloughing,  and  occasionally  undergo 
sarcomatous  metaplasia.     As  a  rule,  they  are  well  defined  from  the  surrounding 


NEW    GROWTHS  305 

tissue  and  can  be  shelled  out  like  uterine  myomata.  Sometimes  they  grow 
diffusely  and  cannot  be  removed  except  by  dissection,  in  which  case  they 
are  found  to  be  adenomyomata,  probably  originating  in  Gartner's  duct. 

The  treatment  of  vaginal  myomata  is  operative  removal. 

Adenomyomas  of  the  rectovaginal  septum  are  comparatively  rare  tumors, 
though  it  is  probable  that  they  are  more  common  than  has  generally  been 
supposed,  many  cases  having  been  overlooked  from  mistaken  diagnosis. 
These  tumors  have  for  some  time  been  recognized  and  a  few  cases  reported. 
Cullen  has  recently  called  attention  to  their  importance  and  has  described 
them  more  accurately  than  has  been  done  heretofore.  As  we  have  not  had 
an  opportunity  to  observe  a  case  we  shall  abstract  freely  from  Cullen's  articles 
on  the  subject. 

Cullen  classifies  adenomyomas  of  the  rectovaginal  septum  as  follows: 

1.  Small  adenomyomas  lying  relatively  free  in  the  rectovaginal  septum. 

2.  Adenomyomas  adherent  to  the  posterior  surface  of  the  cervix  and  at  the 
same  time  to  the  anterior  surface  of  the  rectum. 

3.  Adenomyomas  gluing  the  cervix  and  rectum  together  and  spreading  out 
into  one  or  both  broad  ligaments. 

4.  Adenomyomas  involving  the  posterior  surface  of  the  cervix,  the  rec- 
tum and  broad  ligaments,  and  forming  a  dense  pelvic  mass  that  cannot  be 
liberated. 

In  the  majority  of  cases  the  growth  is  felt  as  a  diffuse  thickening  behind  the 
cervix  in  which  the  cervix  and  rectum  are  involved.  Sometimes  the  mass  is 
nodular,  giving  the  impression  of  an  adherent  myoma.  If  the  tumor  has  grown 
extensively  the  whole  pelvis  floor  and  vaginal  vault  may  be  hard  and  indurated. 
In  the  early  stages  the  tumor  may  be  discrete  and  movable,  usually  attached  to 
the  posterior  wall  of  the  cervix. 

By  rectal  examination  the  tumors  may  usually  be  more  definitely  outlined. 
The  rectal  mucosa  is,  as  a  rule,  not  impaired,  but  the 'tumor  mass  projects  in  the 
lumen  of  the  bowel,  occasionally  constricting  it.  The  rectal  mucosa  over  the 
tumor  mass  may  become  polypoid. 

Histologically,  adenomyomas  of  the  septum  present  the  same  picture  as  seen 
m  the  uterine  adenomyomas.  The  structure  consists  of  unstriped  muscle  and 
connective-tissue  fibers  in  which  are  scattered  singly  or  in  groups  glandular  ele- 
ments of  the  type  seen  in  the  uterine  mucosa.  The  glands  invariably  lie  in  a  bed 
of  cellular  tissue  like  the  stroma  that  surrounds  the  glands  of  the  endometrium. 
Sometimes  the  glands  become  dilated  and  may  form  cysts  of  considerable  size. 
The  histogenesis  of  the  adenomyomas  is  somewhat  vague,  but  on  account  of  their 
characteristic  structure  is  referred  unquestionably  either  to  the  uterine  mucosa  or 
to  rests  of  the  Miillerian  duct. 

The  most  pronounced  symptom  of  these  tumors  is  menorrhagia,  all  the  cases 
reported  by  Cullen  having  occurred  during  the  menstruating  era  and  ranging 

20 


306  GYNECOLOGY 

in  age  from  twenty-five  to  fifty-three.  Pain  with  menstruation  is  not  a  constant 
symptom,  but  may  be  present  and  is  sometimes  very  severe.  As  would  be  ex- 
pected, rectal  pain  is  often  a  prominent  symptom. 

If  the  lumen  of  the  bowel  is  obstructed  the  rectal  discomfort  may  be  great, 
with  frequent  discharges  and  tenesmus. 

When  the  disease  has  spread  out  into  the  broad  ligaments  and  throughout  the 
floor  of  the  pelvis  general  pelvic  discomfort  is  to  be  expected,  with  pains  shooting 
into  the  legs  as  the  result  of  the  involvement  of  nerves  by  the  encroaching  fibrous 
tissue  of  the  tumor. 

The  diagnosis  of  the  adenomyomas  may  be  difficult.  The  condition  most 
likely  to  be  confounded  with  them  is  inoperable  cancer  involving  vagina  and 
rectum.  It  should  be  remembered  that  in  the  adenomyomatous  growths  the 
mucosa  of  the  rectum  is  always  intact  except  for  a  possible  polypoid  hyper- 
trophy. Conditions  of  low-growing  uterine  or  of  cervical  fibroids  combined  with 
chronic  pelvic  and  parametrial  inflammation  may  cause  difficulty  in  exact  differ- 
ential diagnosis.  In  the  latter  cases,  however,  lack  of  involvement  of  the  rectal 
wall  can  usually  be  demonstrated. 

The  surgical  treatment  of  adenomyomas  of  the  rectovaginal  septum  may 
best  be  presented  by  the  following  quotation  from  CuUen: 

"Some  might  argue  that  simple  removal  of  the  appendages  would  cause  atrophy  of  the 
uterine  mucosa  contained  in  the  adenomyomas  of  the  rectovaginal  septum.  My  Case  2  is  a 
sufficient  answer.  Although  a  supravaginal  hysterectomy  had  been  performed  two  years 
before  for  a  myomatous  uterus,  the  pelvic  condition  had  grown  steadily  worse. 

"l.  Where  small  discrete  nodules  exist  in  the  posterior  vaginal  vault,  these  may  be  readily 
removed  through  a  vaginal  incision,  as  was  so  successfully  done  by  Stevens. 

"2.  Where  the  growth  occupiesthe  posterior  surface  of  the  cervix  and  extends  laterally, 
after  the  ureters  have  been  dissected  out  carefully,  a  complete  abdominal  hysterectomy  should 
be  performed. 

"3.  If  the  growth  be  firmly  adherent  to  the  rectum,  a  wedge  of  the  rectum  should  be  removed, 
together  with  the  uterus.  It  has  been  found  best,  after  freeing  the  uterus  on  all  sides,  to 
open  up  the  vagina  anteriorly  and  laterally.  The  uterus  and  the  rectum  can  then  be  hfted 
farther  out  of  the  pelvis,  thus  facilitating  the  removal  of  the  necessary  wedge  of  the  anterior 
rectal  wall.  The  uterus  really  acts  as  a  handle,  and  the  necessary  rectal  tissue  and  the  uterus 
are  removed  as  one  piece. 

"4.  Where  the  lumen  of  the  bowel  is  greatly  narrowed,  a  complete  segment  of  the  rectum 
should  be  removed  with  the  uterus,  and  an  anastomosis  should  be  made. 

"5.  In  desperate  cases,  where  everything  in  the  pelvis  is  glued  together,  an  ideal  operation 
is  out  of  the  question.  The  patient  will  not  stand  a  long  operation,  and,  if  she  could,  a  satis- 
factory result  could  not  be  obtained.  In  such  a  case  it  would  be  better  to  cut  across  the  sig- 
moid, invert  the  lower  end,  close  it,  and  bring  the  upper  end  out  through  the  abdominal  wall 
of  the  left  ihac  fossa,  making  a  permanent  colostomy.  When  the  patient  has  to  some  extent 
regained  her  strength,  the  uterus,  the  lower  portion  of  the  rectum,  and  the  broad  hgament  tissue 
can  be  shelled  out  as  one  piece. 

"These  growths,  while  histologically  not  malignant,  remind  one  of  glue.  Unless  they  are 
completely  removed,  further  trouble  is  liable  to  occur." 


NEW   GROWTHS 


307 


NEW   GROWTHS   OF  THE  UTERUS 

MYOMA   OF   THE   UTERUS 

Uterine  fibroids  are  discrete  fibrous  growths  that  develop  in  the  wall  of  the 
uterus.  These  tumors  are  properly  termed  "fibroids,"  "myomata,"  "fibromy- 
omata,"  or  ''leiomyomata"  (Mallorj^) .  They  are  constituted  of  smooth  muscle 
and  connective-tissue  fibers,  their  histologic  composition  being  similar  to  that  of 
the  uterine  wall.  The  relative  proportion  of  muscle  and  connective  tissue  varies 
greatly  in  different  tumors.  In  general,  the  connective-tissue  element  tends  to 
increase  at  the  expense  of  the  muscle  tissue,  as  the  tumor  grows  older,  a  process 
similar  to  that  which  takes  place  in  the  uterine  wall  after  the  child-bearing  period. 


/^Jt^ 


Fig.  84. — Subserous  Myomata. 


The  histogenesis  of  uterine  fibroids  is  not  definitely  known.  Theories  vari- 
ously ascribe  their  origin  to  the  muscle  cell  of  the  uterus,  to  the  connective-tissue 
cells  of  the  uterus,  to  the  walls  of  the  blood-vessels,  and  to  misplaced  germ  cells. 
The  etiology  is  also  vague.  Numerous  examples  have  been  reported  which 
seem  to  show  that  heredity  may  play  some  part  in  their  causation.  The  relative 
frequency  of  fibroids  in  negroes  suggests  the  influence  of  race  as  an  etiologic 
factor.  The  theory  of  abnormal  ovarian  hormones  as  a  cause  has  been  pre- 
sented, but  not  substantiated.  There  is  no  doubt  that  the  function  of  menstrua- 
tion is  the  most  important  definite  factor  in  the  causation  of  fibroids,  for  they 
develop  only  during  the  menstrual  era.     There  seems  also  to  be  some  relationship 


308 


GYNECOLOGY 


between  fibroids  and  the  child-bearing  function,  in  that  those  who  have  not  borne 
children  are  undoubtedly  somewhat  more  susceptible  to  myomatous  growth  than 
are  those  who  have  been  fertile. 

Uterine  fibroids  develop  chiefly  in  the  wall  of  the  uterus  above  the  internal 
OS,  true  cervical  fibroids  being  rare.  The  particular  location  of  the  tumor  in  the 
uterine  wall  is  a  matter  of  considerable  chnical  importance,  and  fibroids  are, 
therefore,  defined  by  their  position  of  growth.     They  are  divided  into  three 


N/v.v?^<c\\jes. 


^'iG.  85. — Subserous  Myoma  with  Twisted  Pedicle. 
The  omentum  is  shown  adhering  to  the  surface  of  the  tumor.     It  is  in  this  way  that  para- 
sitic myomata  are  formed  and  nourished  by  the  blood-vessels  of  the  adherent  omentum.      (Adapted 
from  Kell5'  and  Cullen.) 

classes:  (1)  The  subserous;  (2)  the  intramural,  and  (3)  the  submucous.  They 
are  also  to  be  distinguished  by  the  direction  in  which  they  are  growing.  Thus, 
a  tumor  which  has  a  tendency  to  develop  away  from  the  uterine  canal  is  called 
centrifugal  in  its  growth,  while  one  that  develops  toward  or  into  the  canal  is 
called  centripetal.  The  direction  of  growth  is  probably  determined  by  the  part 
of  the  uterine  wall  which  offers  the  least  resistance.  I'hus,  a  myoma  beginning 
near  the  outer  surface  would  naturally  grow  toward  the  peritoneal  surface  and 


NEW    GROWTHS 


:309 


become  subserous.  If  it  begins  near  the  uterine  canal  its  direction  of  growth 
would  more  likely  be  toward  the  endometrium,  and  thus  become  submucous.  If 
the  origin  of  the  tumor  is  at  the  center  of  the  uterine  wall,  where  the  resistance 
of  the  tissues  in  both  directions  is  nearly  equalized,  the  tumor  is  likely  to  remain 
as  an  intramural  or  interstitial  fibroid.  Uterine  fibroids  may  appear  as  one 
tumor  or  they  may  be  multiple,  representing  all  three  types  of  development  in 
the  same  uterus. 

Subserous  myomata  indicate  always  centrifugal  development.     This  out- 
ward tendency  of  gro^\d:h  may  continue  until  the  tumor  is  joined  to  the  uterine 


GavxcxV 


lx\\.(2cs\v\vo<.V 
''rl\3v:o\6 


Fig.  86. — Intramural  (or  Interstitial)  Myoma. 


wall  only  by  a  pedicle  through  which  pass  the  blood-vessels  that  give  it  nourish- 
ment. The  centrifugal  growth  may  continue  to  such  an  extent  that  the  tumor 
may,  as  it  were,  ^y  off  at  a  tangent  and  be  entirely  dissociated  from  the  uterus. 
This  is  called  a  floating  or  parasitic  myoma.  The  omentum  usually  attaches 
itself  to  such  a  tumor  and  gives  it  feeble  sustenance  from  its  blood-vessels. 

Interstitial  fibroids  influence  most  the  uterine  wall  and  may  greatly  distort 
the  uterus  and  its  canal.  These  fibroids  do  not  contain  a  definite  capsule,  but 
may  easily  be  shelled  out  from  the  surrounding  uterine  tissue.     They  are  spheric 


310 


GYNECOLOGY 


in  form,  and  are  often  called  "ball  myomata,"  to  distinguish  them  from  the 
adenomyomata  which  infiltrate  the  tissues  of  the  uterus  irregularly  and  cannot 
be  shelled  out. 

Submucous  fibroids  represent  always  a  centripetal  growth.  They  may  en- 
croach on  the  uterine  canal  and  greatly  distort  it,  or  they  may  become  peduncu- 
lated and,  growing  downward  in  the  canal,  distend  the  cervix  and  present  at  the 
external  os.  They  also  may  spontaneously  separate  from  the  uterus  and  be 
delivered  through  the  vagina.  Submucous  fibroids  cause  a  general  hypertrophy 
of  the  uterus  and  cervix.     The  endometrium  covering  the  tumor  is  thinned  out, 


(0¥-  ^ 


Fig.  87. — Submucous  Myoma. 


but  that  of  the  rest  of  the  canal  is  hypertrophied  and,  as  we  shall  see,  is  the  chief 
source  from  which  abnormal  bleeding  issues. 

Sometimes  a  centrifugally  growing  myoma  develops  from  the  side  of  the 
uterus  outward  between  the  leaves  of  the  broad  ligament,  forming  a  so-called 
intraligamentary  fibroid  or  myoma. 

Myomata  rarely  develop  originally  below  the  level  of  the  internal  os  in  the 
cervical  tissue,  though  they  do  occasionally.  Most  so-called  cervical  fibroids 
originate  in  the  lower  uterine  segment  and,  growing  downward,  encroach  on  or 
''take-up"  the  cervical  tissue. 


NEW    GROWTHS 


311 


True  cervical  myomata  are  quite  uncommon,  but  their  occurrence  is  apt  to 
be  serious.  They  do  not  have  the  same  latitude  of  growth  as  do  myomata  of 
the  body,  so  that  they  cause  pressure  sj^mptoms  comparatively  early.  They 
may  almost  completely  fill  the  lower  part  of  the  pelvis,  obstructing  the  bladder 
and  rectum.  On  account  of  their  location  extirpation  is  difficult  and  danger- 
ous. 

Degeneration  of  Myomata. — Uterine  myomata  are  prone  to  numerous  forms 
of  degeneration,  most  of  which  are  the  result  of  the  inadequate  blood-supply 
that  usually  characterizes  these  tumors. 


~1rur\bo^\JterL 


OuV)WUC00S     • 
^\)OW0— 

Pe.b\jtvc\)\a\e'6 


WP.&-. 


Fig.  88. — Pedunculated  Submucous  Myoma  Extruding  from  the  External  Os. 


Hyaline  Degeneration. — This  form  of  degeneration  occurs  in  some  part  of 
nearly  all  fibroids.  Its  significance  is  only  microscopic  and  is  of  no  special 
clinical  importance. 

Changes  Due  to  Passive  Congestion. — In  this  condition  the  tumor  becomes 
charged  to  a  greater  or  less  extent  with  the  watery  constituents  of  the  blood. 
Three  forms  are  distinguished — edematous,  myxomatous,  and  cystic. 

In  the  edematous  form  the  tumor  becomes  largjer  and  softer  as  a  result  of 


312 


GYNECOLOGY 


the.  serous  exudate  from  obstructed  venous  circulation.     This  may  result  from 
torsion  of  a  pedunculated  fibroid  or  from  torsion  of  the  entire  myomatous 


^         „»ii^ 


Fig.  89. ■ — Contour  of  Abdomen  with  Large  Uterine  Fibroid.     (After  a  photograph.) 


Fig.  90. — Contour  of  Abdomen  with  Uterine  Fibroid.     (After  a  photograph.) 


uterus,  or  from  any  interference  with  the  venous  exit  of  blood  from  the  tumor. 
The  apparent  rapid  growth  of  fibroids  is  often  due  to  enlargement  simply  from 
edema. 


NEW    GROWTHS 


313 


|F7 


VunausUtefc 
Conto.vt\>.np 


X\c^i  Koonbli'.o 


.3<V.u0rt\O — 


VtvoLna 


CeroicoX  J^vijOicncN . 


\vi  ,T».  G  vux)  •c'^^  b  fci.  V  cy 


fT- 


■J 

Fig.  91. — Cervical  Myoma. 
The  drawing  is  from  a  specimen  removed  by  operation.     The  lower  two  masses  represent  two 
enormous  cervical  fibroids,  one  filling  the  pouch  of  Douglas  and  the  other  extending  down  into  the 
vagina  nearly  to  the  introitus.     The  vaginal  wall  was  removed  during  the  operation  and  is  seen  in  the 
drawing  surrounding  the  lower  myoma. 


.  Myxomatous  degeneration,  so-called,  is  a  misleading  term.  It  is  simply  an 
advanced  form  of  edema  as  a  rule.  The  connective-tissue  cells  become  so  widely 
separated  by  the  infiltrating  serous  fluid  that  they  closely  resemble  microscop- 


314 


GYNECOLOGY 


ically  true  myxomatous  cells.  A  better  term  for  this  change  would  be  myxoma- 
toid  degeneration. 

Cystic  degeneration  in  some  cases  represents  a  still  more  marked  serous 
infiltration  by  which  the  fluid  exudate  becomes  confined  in  certain  areas,  so 
as  to  create  cavities  in  the  tissue  of  the  tumor.  Enormous  cysts  may  form  by 
the  coalescing  of  smaller  cysts. 

Cystic  formation  in  uterine  fibroids  also  results  from  other  causes  than 
passive  congestion.  Changes  in  the  blood-  and  lymph-vessels  may  produce 
cystic  tumors  of  the  angiomatous  and  lymphangiectatic  type.  In  some  of  the 
large  cystic  myomata  there  is  doubtless  an  abnormal  secretory  action  on  the 


Fig.  92. — Hyaline  Degeneration  of  Fibroid. 


part  of  the  cells  lining  the  cysts,  such  as  occurs  in  the  cystic  change  of  adeno- 
myomata.  Cysts  may  also  result  from  a  local  necrosis  of  the  myoma  with  hque- 
f action  of  the  tissues.  This  is  sometimes  seen  in  fibroids  that  have  been  treated 
by  radiation.  In  some  cases  the  cysts  originate  in  the  glandular  elements  of  an 
adenomyoma. 

Red  degeneration  relates  to  a  form  of  degeneration  characterized  by  a  bright 
red  color  of  the  tissue.  There  are  two  types  of  red  degeneration,  the  thrombotic 
and  the  angiomatous.  The  thrombotic  type  is  especially  common  in  tumors 
complicating  pregnancy.  These  tumors  degenerate  rapidly  and  easily  become 
•infected.     They  usually  grow  rapidly  and  may  be  very  painful  and  exquisitely 


NEW   GROWTHS 


315 


tender  to  the  touch.  They  are  apt  to  be  attended  with  fever  and  other  consti- 
tutional symptoms. 

The  angiomatous  tumors  show  free  blood  on  the  cut  surface  from  numerous 
thin-walled  blood-vessels.  They  are  clinically  less  important  than  those  of  the 
thrombotic  type. 

Fatty  Degeneration. — This  form  of  degeneration  takes  place  especially  during 
pregnancy.     Fat  areas  may  be  seen  scattered  throughout  the  tumor  or  the 


Fig.  93. — Fibeomyoma  with  Cystic  Degeneration. 
Low  power.     The  section  contains  irregular  cavities  which  were  filled  with  a  thick,  cloudy  fluid. 
The  section  is  taken  from  the  edge  of  a  large  cavity,  the  condition  being  due  to  necrosis.     The  nuclei 
of  the  muscle-cells  are  cut  in  cross-section.     There  is  a  marked  infiltration  with  leukocytes. 


tumor  may  be  almost  entirely  converted  into  fat.     Fatty  degeneration  is  also 
seen  in  atrophied  fibroids  following  the  menopause. 

Necrosis  of  fibroids  occurs  when  they  become  deprived  of  their  blood-supply. 
This  is  apt  to  happen  during  pregnancy  and  constitutes  a  dangerous  complica- 
tion. Pedunculated  fibroids  may  become  necrotic  as  a  result  of  torsion.  Partial 
necrosis  with  cyst  formation  may  occur  without  causing  symptoms  unless  infec- 
tion takes  place.     If  the  surface  of  the  fibroid  takes  part  in  the  necrosis  the 


316 


GYNECOLOGY 


results  are  more  serious,  for  the  damaged  peritoneum  may  cause  adhesions  to 
the  intestines,  and  from  this  source  there  is  greater  danger  of  infection. 

Red  degeneration  is  also  applied  to  the  early  stage  of  necrosis,  especially 
that  seen  in  connection  with  pregnai;cy.  The  necrosis  begins  in  the  center  of 
the  tumor.  The  myomatous  tissue  loses  its  elas.ticity,  and,  as  a  result  of  diffu- 
sion of  the  blood  coloring-matter,  becomes  pink  or  flesh  colored.  As  the  necro- 
sis progresses  the  color  becomes  brown  and  greenish.  In  the  end  the  tissue 
sometimes  becomes  chy  and  crumpled  or  sometimes  liquefied. 


?-  '-  'Jf/'Ti 


•pfi  r 


■^  ,V 


VI 


Fig.  94. — Fibromtoma  with  Hemorrhage. 

Low  power.     Scattered  through  the  section  are  masses  of  blood-corpuscles  and  single  corpuscles. 

The  blood-vessels,  as  can  be  seen  near  the  center  of  the  section,  are  dilated. 

Calcification  represents  a  deposit  of  lime  salts  in  the  tissue  of  the  tumor. 
This  occurs  in  long-existing  fibroids,  and  is  seen  usually  after  the  menopause. 
The  calcified  process  may  be  in  scattered  areas  or  may  involve  the  entire  tumor. 
If  there  are  multiple  fibroids  the  calcification  may  appear  in  some  of  the  tumors 
and  not  in  others. 

Regressive  Changes. — After  the  menopause  a  change  takes  place  in  the  tissue 
of  the  fibroid  like  that  which  occurs  in  the  uterus.  The  change  consists  princi- 
pally in  a  diminishing  proportion  of  muscular  to  connective  tissue.  The  con- 
nective tissue  gradually  loses  its  cellular  elements  and  approaches  cicatricial 


NEW   GROWTHS 


317 


tissue  in  character.  There  is  a  consequent  shrinking  of  the  tumor  bulk.  This 
atrophy  of  uterine  fibroids  has  led  to  the  belief  that  they  disappear  or  are  "ab- 
sorbed" after  the  menopause.     They  probably  never  disappear. 

'  Regressive  or  atrophied  fibroid  tumors  are  not  to  be  regarded  as  beyond 
the  pale  of  danger,  for  they  are  especiallj-  prone  to  various  forms  of  degenera- 
tion. 

Atrophy  of  fibroids  is  not  entirely  confined  to  the  menopause,  for  it  is  some- 
times observed  during  the  puerperium. 


sf 


s^- 


J>.iy 


n' 


Fig.  95.- — Fibromyoma  with  Necrosis. 
Low  power.      Much  of  the  tissue  has  become  necrotic,  leaving  material  of  a  thick  fluid  consistency 
which  has  no  definite  structure  microscopically,  infiltrated  with  a  few  leukocytes.     The  myomatous 
tissue  is  preserved  along  the  blood-vessels,  as  is  well  shown  to  the  right  of  the  drawing. 

Sarcomatous  Change. — The  so-called  malignant  degeneration  of  fibroids  occurs 
most  commonly  in  long-existing  tumors  after  the  menopause.  The  change 
starts  usually  at  some  localized  point  near  the  center  of  the  growth.  The  entire 
tumor  may  become  involved  and  be  the  starting-point  of  distant  metastases. 
There  is  a  wide  variation  in  the  estimates  of  the  frequency  with  which  sarcoma- 
tous change  takes  place.  This  is  most  generally  put  at  5  per  cent.  More  recent 
investigations  with  improved  staining  methods  have  demonstrated  that  many 
of  the  diagnoses  are  erroneous,  and  that  the  actual  proportion  is  nearer  1  per 
cent.     (See  also  Sarcoma  of  Uterus.) 


318 


GYNECOLOGY 


In  order  to  make  an  exact  diagnosis  between  a  myoma  rich  in  cells  and  a  myosarcoma  Raab 
recommends  the  following  points  for  consideration: 

(1)  Structure  of  the  muscular  tissue  and  its  richness  in  cells;  (2)  changes  in  the  nuclei;  (3) 
division  of  the  nuclei;  (4)  content  of  intercellular  fibrils  (hyaline) ;  (5)  giant-ceUs;  (6)  boundaries 
of  the  tumor. 

Other  important  points  are  that : 

1.  Rich  cell  content  and  limited  development  of  connective  tissue  cannot  settle  the  diagno- 
sis of  myosarcoma,  since  ordinary  myomata,  rich  in  cells,  may  show  the  same  condition. 

2.  The  nucleus  in  myosarcoma  does  not  show  any  decided  change  in  form  in  contrast  to 
that  of  ordinary  myoma. 


Fig.  96. — Fibromyoma  with  Calcification. 
Low  power.     The  darker  areas  scattered  through  the  tissue  are  areas  of  beginning  calcification. 
Their  irregular  outlines  and  deep  staining  properties  are  characteristic.     The  tissue  on  the  right  is 
poor  in  nuclei  and  consists  largely  of  connective  tissue. 


3.  The  mere  presence  of  division  of  nuclei  cannot  be  taken  as  decisive.  It  is  decisive  only 
if  abundant,  and  examination  should  be  directed  chiefly  to  the  youngest  parts  of  the  tumor  that 
have  not  yet  undergone  regressive  metamorphosis. 

4.  Hyaline  degeneration  is  more  likely  to  take  place  in  myomata  and  is  perhaps  to  be 
regarded  as  a  cicatricial  process. 

5.  Giant-cells  have  a  special  value  in  the  diagnosis  of  malignancy.  They  may  appear  very 
rarely  in  benign  myomata,  but  if  found,  they  are  isolated.  They  appear  in  great  numbers  in 
myosarcoma  and  with  especial  abundance  in  the  boundaries  of  the  hyaline  masses. 

6.  Benign  tumors  show  sharply  circumscribed  boundaries.  Myosarcomata  do  not  show 
a  real  infiltrating  proliferation,  but  a  penetration  into  the  lymph- vessels  (Kohler). 


NEW    GROWTHS 


319 


Adenocarcinoma  of  the  endometrium  is  not  infrequently  associated  with 
myomata.  This  combination  occurs  more  commonly  in  the  large,  long-existing 
tumors.  It,  of  course,  is  not  in  any  sense  a  carcinomatous  degeneration  of  the 
fibroid,  as  the  two  processes  are  histologically  entirely  distinct.  It  is  probable 
that  the  myomatous  growth,  acting  mechanically  as  an  irritant  to  the  endo- 
metrium, encourages  the  mahgnant  process. 


Fig.  97. — Fibromyoma  with  Carcinoma. 
Low  power.     Most  of  the  section  consists  of  fibromyomatous  tissue  in  process  of  necrosis,  with  an 
infiltration  of  leukocytes.     Four  areas  of  carcinomatous  tissue  are  seen,  the  centers  of  two  of  which 
are  necrotic.     This  area  was  found  in  the  center  of  a  polyp.     The  case  is  extremely  rare. 


In  very  rare  instances  a  myomatous  polyp  of  the  uterus  may  become  permeated  with  a 
carcinomatous  growth.  In  a  case  operated  on  by  the  author  a  necrotic  myoma  was  removed 
from  the  cervical  canal  in  an  elderly  woman.  The  polyp,  both  macroscopically  and  microscop- 
ically, was  that  of  a  pedunculated  fibroid  about  the  size  of  an  English  walnut.  Through  portions 
of  the  tumor  were  found  areas  of  squamous  cell  carcinoma,  though  there  was  no  apparent  trace 
of  mahgnant  disease  in  the  cervical  tissue.  The  disease  later  recurred  in  the  parametrimn. 
Von  Winewater  reported  a  very  similar  case  (Arch.  f.  Gyn.,  1912)  in  which  there  was  an  adeno- 
carcinomatous  invasion  of  a  pedunculated  myoma.  In  his  case  the  uterus  was  removed.  Al- 
though adenocarcinoma  was  found  throughout  the  myoma,  the  uterine  wall  was  entirely  free 
from  malignant  invasion.  He  thinks  that  the  disease  originated  in  the  pedicle  of  the  myoma 
and  spread  into  the  tumor  rather  than  into  the  uterine  wall,  following  the  lines  of  least  resistance. 


320  GYNECOLOGY 

Infection. — Uterine  myomata  may  become  infected  in  several  ways.  Super- 
ficially they  may  take  part  in  a  pelvic  peritonitis  that  results  from  a  gonorrheal 
or  puerperal  infection.  The  inflammation  in  this  case  is  confined  to  the  peri- 
toneal covering  of  the  tumor  and  is  manifested  by  adhesions.  Necrotic  myomata 
become  adherent  as  a  result  of  a  damaged  peritoneal  covering.  The  injury  to 
the  peritoneum  is  caused  by  obstruction  of  the  peripheral  blood-supply. 

Fibroids  may  also  become  adherent  to  peritoneal  surfaces  if  the  pressure  is 
great  enough  or  is  exerted  against  hard  surfaces  so  as  to  traumatize  the  serous 
membrane.  A  necrotic  fibroid  adherent  to  the  intestines  may  result  in  serious 
infection  and  peritonitis,  the  path  of  infection  being  through  the  wall  of  the 
intestines.  This  is  one  of  the  special  dangers  that  threaten  fibroids  associated 
with  pregnancy. 

Another  form  of  infection  is  that  which  reaches  the  myoma  through  the 
general  circulation.  This  has  been  proved  by  the  finding  of  pathogenic  germs 
in  the  tissues  of  fibroids  and  explains  the  elevated  temperature  which  some 
myomatous  women  show.  It  must  also  explain  many  cases  of  acute  pelvic 
inflammation  which  complicate  uterine  fibroids  where  gonorrheal  and  puerperal 
infection  can  be  positively  ruled  out.  These  inflammations  are  sometimes  very 
extensive,  involving  the  adnexa  and  resulting  in  large  pelvic  abscesses. 

Polypoid  submucous  myomata  frequently  become  infected  and  gangrenous. 
Occasionally  during  the  puerperium  subserous  myomata  suppurate. 

Frequency. — Uterine  myomata  occur  with  extraordinary  frequency.  At 
least  40  per  cent,  of  all  women  have  fibroids,  while  nearly  all  single  women  of 
middle  age  have  them.  Only  a  certain  percentage  of  the  tumors,  however,  give 
trouble,  many  of  them  remaining  entirely  insignificant.  It  is  rare  to  see  fibroids 
in  women  under  twenty-five  years  of  age.  Most  tumors  begin  their  growth 
between  the  ages  of  twenty-five  and  forty,  and  if  they  cause  symptoms  they 
become  subject  to  treatment,  most  commonly  between  the  ages  of  forty  and 
fifty.  After  the  menopause  it  is  doubtful  if  new  tumors  ever  develop.  Thus, 
it  will  be  seen  that  the  origin  of  growth  of  fibroids  parallels  somewhat  closely 
the  child-bearing  era.  The  rate  of  growth  varies  widely.  Usually  it  is  very 
slow,  and  it  may  take  several  years  for  a  myoma  to  become  large  enough  to 
attract  attention.  Occasionally  one  takes  on  a  very  rapid  development,  and 
it  is  tumors  of  this  kind  that  have  been  frequently  mistaken  for  sarcomata. 
The  microscopic  appearance  of  rapidly  growing  myomatous  cells  is  very  like 
sarcoma  and  can  only  be  distinguished  by  expert  examination.  In  manj^  in- 
stances the  apparent  rapid  enlargement  of  a  fibroid  is  not  due  to  an  actual 
multiplication  of  the  myomatous  elements,  but  to  edema  or  some  form  of  de- 
generation or  inflammation.  "^ 

Fibroids  associated  with  pregnancy  usualty  enlarge,  though  they  may 
diminish,  in  size.  Sometimes  there  is  a  temporary  enlargement,  followed  by  a 
cessation  of  growth  or  even  an  atrophy.  The  enlargement  of  a  fibroid  after 
the  menopause  is  always  due  to  some  form  of  degeneration. 


NEW   GROWTHS  321 

Symptoms. — The  symptomatology  of  uterine  fibroids  depends  to  a  great 
extent  on  the  location  of  the  tumor.  If  favorably  placed,  a  myomatous  tumor 
may  grow  to  a  large  size  without  giving  the  patient  the  slightest  discomfort. 

A  subserous  fibroid  growing  toward  the  abdominal  cavity  may  be  sup- 
ported by  the  brim  of  the  pelvis.  By  drawing  the  uterus  with  it,  the  fibroid, 
instead  of  causing  pelvic  pressure,  acts  in  exactly  the  opposite  direction,  so  that 
patients  may  carry  one  of  these  tumors  for  years  without  noticing  it.  In  fact, 
many  patients,  feeling  the  hard  lump  in  the  abdomen,  regard  it  as  a  normal 
part  of  their  anatomy. 

If,  however,  the  tumor  is  so  located  as  to  cause  pelvic  pressure,  symptoms 
ensue.  Thus,  a  fibroid  growing  in  the  lower  posterior  wall  of  the  uterus  is  more 
likely  to  exert  downward  pressure  on  the  pelvic  supports  than  one  that  is  grow- 
ing in  the  fundus.  This  downward  pelvic  pressure,  in  whatever  way  it  is  caused, 
represents  one  of  the  most  important  phases  of  all  gynecologic  symptomatology. 
The  patient  is  almost  continually  conscious  of  a  bearing-down  discomfort,  which, 
without  giving  actual  pain,  serves  in  time  to  become  a  serious  drain  on  the 
general  health.  Patients  with  this  symptom  cannot  be  on  their  feet  long  with- 
out becoming  tired.  Working  women  become  worn  and  exhausted,  while  the 
well-to-do  are  prevented  from  taking  part  in  the  various  activities  to  which  they 
are  accustomed.  The  ill  effect  of  pelvic  pressure  on  the  general  nervous  system 
is  of  great  clinical  importance,  and  must  be  borne  in  mind  in  considering  the 
treatment  of  uterine  fibroids. 

Besides  producing  the  effect  of  weight  and  general  pelvic  pressure,  fibroids 
may  cause  other  pressure  symptoms.  A  tumor  encroaching  on  the  rectum 
may  cause  constipation.  It  does  this  partly  by  obstructing  the  lumen  of  the 
bowel  and  partly  by  interfering  with  the  muscular  peristalsis  of  the  rectal  wall. 
Occasionally  an  impacted  myoma  may  entirely  obstruct  the  bowel.  Fibroids 
on  the  anterior  wall .  of  the  uterus  may  cause  symptoms  of  irritation  of  the 
bladder,  though  this  occurs  less  commonly  than  one  might  suppose.  They 
have  been  known  to  cause  by  pressure  complete  suppression  of  the  urine.  Tumors 
that  obstruct  the  bladder  usually  develop  from  the  cervix. 

It  is  possible  for  a  myoma  to  grow  in  such  a  way  as  to  press  on  the  sciatic 
nerve  and  cause  pain  in  the  leg.  Large  tumors  are  often  attended  with  cyanosis 
and  palpitation  as  a  result  of  their  size  and  weight. 

Uncomplicated  fibroids  are  not  tender  and  ordinarily  do  not  give  pain, 
except  occasionally  in  connection  with  menstruation. 

Pelvic  pain  and  tenderness  usually  signify  an  inflammatory  process.  If 
the  process  is  active,  the  course  is  that  of  any  pelvic  inflammation.  Painful 
and  tender  fibroid  tumors,  where  there  is  no  active  inflammation,  as  a  rule, 
indicate  adhesions.  A  sudden  acute  abdominal  attack  is  sometimes  the 
result  of  torsion  and  demands  immediate  operation. 

Interstitial  fibroids  are  very  apt  to  cause  dysmenorrhea,  while  intermenstrual 
pain  is  a  very  frequent  sign  of  interstitial  growth. 

21 


322  GYNECOLOGY 

The  most  important  effect  of  fibroids  is  uterine  bleeding  in  the  form  of  menor- 
rhagia.  The  catamenia  is  characterized  bj^  a  more  profuse  flow,  the  appearance 
of  clots  in  the  menstrual  blood,  and  a  prolongation  of  the  period  beyond  its 
normal  limits.     There  is  usually  a  shortening  also  of  the  intermenstrual  period. 

All  three  forms  of  these  tumors  may  cause  abnormal  uterine  bleeding,  but 
it  more  commonly  comes  from  the  submucous  or  centripetally  growing  type. 
Centrifugal  tumors  may  grow  to  an  enormous  size  without  producing  menor- 
rhagia.  The  continued  menorrhagia  of  bleeding  fibroids  results  in  serious 
detriment  to  the  patient's  health.  A  secondary  anemia  always  ensues  and  the 
hemoglobin  may  be  reduced  as  low  as  25  per  cent,  or  even  10  per  cent. 

Besides  the  constitutional  symptoms  resultant  on  the  frequent  losses  of 
blood,  bleeding  fibroids  produce  a  very  deleterious  effect  on  the  nervous  sys- 
tem, espeeialty  if  there  be  a  neurotic  predisposition. 

Polypoid  submucous  fibroids,  besides  causing  menorrhagia,  may. also  cause 
metrorrhagia.  This  is  due  to  the  fact  that  these  tumors  usually  become  necrotic 
and  the  intermenstrual  blood  comes  from  the  macerated  surface.  Hemorrhages 
from  this  source  may  be  ver\'  alarming.  It  should  be  remembered,  however, 
that  the  bleeding  from  fibroid  tumors  is  always  venous,  and,  therefore,  almost 
never  fatal. 

Necrotic  polypoid  submucous  fibroids  cause  a  foul  leukorrheal  discharge 
which  in  odor  and  consistency  closely  resembles  that  from  cancer  of  the  cervix. 

There  are  certain  changes  that  appear  in  other  organs  of  the  body  with 
sufficient  frequency  in  connection  with  fibroid  tumors  to  have  led  to  the  belief 
that  the  growths  bear  some  causal  relationship  to  the  associated  condition. 
The  principal  secondary  conditions  in  this  connection  are  heart  lesions,  hyper- 
thyroidism, and  diabetes.  Of  these,  heart  lesions  occur  most  frequently,  and 
appear  sufficiently  often  to  have  earned  the  appellation  of  "myoma  heart." 
Disturbances  of  the  heart  are  usually  seen,  either  in  connection  with  large 
long-standing  myomata  in  women  past  middle  life  or  where  there  has  been 
long-continued  menorrhagia  and  secondary  anemia.  The  fundamental  condi- 
tion of  the  heart  is  that  of  compensatory  dilatation,  which  usually  rights  itself 
after  the  removal  of  the  tumor.  If,  how^ever,  the  case  is  neglected  the  heart 
may  lose  its  compensation  (see  also  page  115  j. 

Fibroids  and  Pregnancy. — The  relationship  between  pregnancy  and  uterine 
myomata  is  a  subject  of  much  importance,  for  not  only  does  pregnancy  affect 
the  growth  of  the  tumors  in  various  ways,  but  the  tumors  exert  a  dangerous 
influence  over  the  course  of  pregnancy. 

Fibroids,  as  we  have  seen,  may  take  on  a  very  rapid  growth  during  preg- 
nancy. In  this  process  the  myomatous  elements  seem  to  share  in  the  phj^siologic 
hypertrophy  of  the  uterine  wall.  The  enlargement  of  the  myoma  may  Ije  per- 
manent or  the  tumor  may  become  regressive  after  the  birth  of  the  child.  Some- 
times fibroids  atrophy  during  pregnancy,  but  this  is  not  the  rule.  The  blood- 
supply  of  fibroids  during  pregnancy  is  usually  diminished,  especially  if  they  are 


NEW   GROWTHS  323 

subserous  or  pedunculated,  and  this  constitutes  a  very  serious  danger,  for  it 
may  result  in  necrosis  of  the  tumor  and  subsequent  infection.  Fatty  degenera- 
tion of  the  tumors  is  one  of  the  changes  that  take  place  during  pregnancy. 

Of  the  influences  that  fibroids  exert  on  the  course  of  pregnancy,  abortion  is 
one  of  the  most  common.  It  is  probable  that  interstitial  tumors  disturb  the 
muscular  tension  of  the  uterine  wall,  so  that  abnormal  contractions  occur  suffi- 
cient to  dislodge  the  ovum. 

Submucous  fibroids  produce  abnormal  changes  in  the  endometrium.  It  is 
thinned  and  flattened  over  the  surface  of  the  tumor,  while  the  remainder  becomes 
permanently  hypertrophiecl.  The  endometrium  may,  therefore,  become  poor 
soil  for  the  continued  gro'^i;h  of  the  ovum. 

Undoubtedly,  fibroids  to  some  extent  prevent  impregnation.  This  is  denied 
by  some,  but  authentic  figures  seem  to  show  that  the  percentage  of  sterility  in 
myomatous  women  is  higher  than  in  normal  women.  The  average  proportion 
of  sterility  in  all  women  is  between  12  and  15  per  cent.,  while  that  in  myomatous 
women  is  about  30  per  cent.  Just  why  a  myomatous  predisposition  causes 
sterihty  is  not  known.  On  the  other  hand,  it  has  been  claimed  that  fibroids, 
by  prolonging  the  menstrual  era,  sometimes  favor  fertilit3\ 

Myomata  that  are  large  or  so  placed  as  to  obstruct  the  uterine  canal  may  act 
as  a  serious  interference  to  childbirth. 

The  relationship  between  .myomata  and  the  function  of  menstruation  is  a 
matter  of  interest.  Women  who  develop  fibroids  are  apt  to  give  a  history  of 
having  begun  to  menstruate  at  an  especially  early  age.  Thej^  also  continue  to 
menstruate  to  a  later  age  than  the  average,  the  menopause  coming  at  fifty  or  over. 
Myomatous  women  usually  menstruate  profusely  from  the  time  the  catamenia  is 
estabhshed,  and  clotting  of  the  menstrual  blood  often  occurs  long  before  evi- 
dences of  fibroid  growth  appear. 

The  diagnosis  of  uterine  fibroids  is,  in  the  majority  of  cases,  attended  with 
little  difficulty.  The  characteristic  hard,  nodular,  asymmetric  feel  of  the  uterus 
is  usually  unmistakable;  nevertheless,  there  are  many  chances  for  error. 

In  palpating  the  abdomen  the  most  important  sign  is  the  ability  to  feel  the 
fundus  of  the  uterus  just  back  of  the  pubes.  In  the  absence  of  pregnancy  this 
incficates  a  fibroid  uterus  in  the  vast  majority  of  cases,  though  it  must  be  remem- 
bered that  it  may  result  from  a  tumor  of  the  adnexa  in  the  posterior  culdesac, 
which  is  pushing  the  uterus  forward  toward  the  anterior  abdominal  wall.  An 
adherent  tumor  of  this  kind,  whether  of  "the  ovary  or  of  the  Fallopian  tube,  creates 
with  the  uterus  a  mass  which  is  often  mistaken  for  a  fibroid  uterus,  a  mistake  in 
diagnosis  that  may  be  made  by  the  most  expert.  The  error,  however,  is  not 
serious,  for  if  there  are  symptoms,  either  condition  indicates  an  abdominal  ope- 
ration. 

A  well-advanced  cancer  of  the  body  of  the  uterus  is  often  difficult  to  dis- 
tinguish from  a  symmetric  edematous  fibroid.  If  there  has  been  metrorrhagia, 
suspicion  of  cancer  should  be  aroused,  and  it  is  advisable  to  make  a  prehminary 


324  GYNECOLOGY 

intra-uterine  exaixdnation,  with  removal  of  a  specimen  for  microscopic  diagnosis. 
This  is  important,  since  even  after  the  abdomen  is  opened  it  may  not  be  possible 
to  distinguish  between  the  two  conditions.  A  correct  diagnosis  is  essential,  be- 
cause if  the  tumor  is  a  fibroid,  supravaginal  hysterectomy  is  indicated,  while  if 
it  is  cancer  of  the  body,  a  complete  hysterectomy,  preferably  by  Wertheim's 
method,  should  be  performed. 

The  diagnosis  between  pregnancy  and  a  myomatous  uterus  is  sometimes  ex- 
ceedingly difficult  and  may  lead  to  disastrous  procedures.  A  symmetric  edema- 
tous myoma  may  resemble  a  pregnant  uterus  very  closely  indeed.  When  there 
is  doubt  between  these  two  conditions,  the  most  rehable  help  is  from  the  history 
of  menstruation.  Pregnancy  causes  amenorrhea  and  fibroids  tend  to  cause 
menorrhagia,  yet  it  must  be  borne  in  mind  that  pregnant  women  sometimes 
bleed  periodically,  while  fibroids  occasionally  are  associated  with  temporary 
amenorrhea.  Other  incidental  signs  are  helpful.  Of  these,  the  consistency  of  the 
cervix  is  most  valuable.  The  cervix  of  a  myomatous  uterus  does  not  exhibit  the 
softness  characteristic  of  pregnancy.  If,  however,  there  is  a  severe  laceration 
with  eversion  of  the  fips,  the  sign  may  be  doubtful.  The  condition  of  the  breasts, 
the  presence  or  absence  of  blueness  of  the  vaginal  mucous  membrane,  are  inci- 
dentally valuable.  If  on  opening  the  abdomen  doubt  still  exists,  something 
can  be  told  from  the  color  of  the  uterus.  A  myomatous  uterus  has  rather  a  pmk- 
ish  hue,  while  that  of  the  pregnant  one  is  a  deep  purple.  If  doubt  still  exists,  it 
is  best  to  incise  the  uterine  wall  in  a  longitudinal  chrection,  by  which  a  certain 
diagnosis  can  be  made  at  once.  The  corpus  luteum  sometimes  indicates  the 
real  condition,  but  is  not  entirely  rehable.  If  it  is  very  large,  it  throws  ad- 
ditional e^-idence  in  favor  of  pregnancy. 

The  use  of  the  uterine  sound,  formerly  so  commonly  used  in  the  diagnosis  of 
uterine  myomata,  is  not  recommended  under  any  concUtion.  The  information 
gained  from  it  is  of  httle  value,  while  the  dangers  in  its  use  are  considerable.  The 
Abderhalden  test  for  pregnancy  is  especially  valuable  in  differentiating  fibroids 
from  pregnant  uteri. 

The  treatment  of  uterine  myomata  depends  on  their  size,  rapidity  of  gro"^i:h, 
and  the  production  of  sjonptoms.  ]\Iany  fibroids  require  no  treatment  at  all. 
Small  subserous  tumors  that  are  either  stationarj^  or  growing  very  slowly,  and 
which  are  causing  no  symptoms,  may  be  let  alone,  but  should  be  kept  under 
periodic  observation,  especially  if  the  patient  is  hkely  to  become  pregnant. 
Atrophied  fibroids  of  moderate  size  after  the  menopause  do  not  need  treatment 
if  they  are  giving  no  symptoms,  but  should  be  carefully  watched  for  evidences  of 
degeneration. 

Large  fibroids,  when  discovered,  should,  as  a  rule,  be  removed  even  if  thej^  are 
causing  no  discomfort,  for  they  are  practically  sure  to  give  trouble  sooner  or  later, 
and  their  removal  is  safer  and  easier  if  it  is  done  before  serious  symptoms  or  com- 
pHcations  take  place. 

Fibroids  that  cause  symptoms  should  in  most  cases  be  treated  surgically. 


NEW    GROWTHS  325 

The  symptoms  that,  require  surgical  intervention  are  those  that  result  from 
bleeding,  pressure,  infection,  and  degeneration.  It  is  obvious  that  symp- 
toms from  the  last  three  conditions  named  can  only  be  treated  by  surgical 
operation. 

Bleeding,  however,  when  not  due  to  degenerative  processes  in  the  tumor, 
may  be  subject  sometimes  to  other  forms  of  treatment  than  surgery.  As  we 
have  seen,  the  bleeding  from  a  submucous  myoma  comes  from  the  hypertrophied 
endometrium  not  covering  the  tumor.  It  is,  therefore,  possible  sometimes  to 
reheve  the  menorrhagia  by  curetment.  The  relief  is,  however,  usually  only 
temporary.  The  procedure  is  especially  useful  in  tiding  a  patient  over  the 
menopause,  with  the  hope  of  a  future  atrophy  of  the  tumor.  This  form  of  treat- 
ment is  to  be  used  only  in  small  or  moderately  sized  fibroids. 

There  are  various  drugs  that  are  in  common  use  for  treating  menorrhagia 
due  to  fibroids,  most  prominent  of  which  are  ergot,  hydrastis,  and  hamamelis. 
The  results  of  their  use  are,  however,  very  unsatisfactory.  Recently  pituitrin 
has  come  into  favor,  and  encouraging  reports  have  been  made  in  its  administra- 
tion for  the  control  of  non-puerperal  uterine  bleeding. 

In  some  cases  the  bleeding  from  fibroids  may  be  controlled  by  the  use  of 
radium  or  the  a;-rays.  The  effect  of  radiation  results  in  the  destruction  of  the  folli- 
cles of  the  ovaries,  which,  according  to  our  present  knowledge,  preside  over  men- 
struation. Whether  radiation  affects  the  bleeding,  in  addition,  bj^  direct  effect  on 
the  uterine  tissues  is  a  matter  of  conjecture.  This  form  of  treatment  undoubt- 
edly has  a  valuable  place  in  the  therapy  of  fibroids  in  certain  cases,  especially  in 
patients  who  are  near  the  menopause  or  who  are  constitutionally  unfit  for  surgi- 
cal operation.  The  treatment  has  certain  disadvantages  which,  for  the  present 
at  least,  greatly  restrict  its  field  of  usefulness.  Besides  the  ordinary  danger  of 
burns  in  the  application  of  radiation  there  is  very  serious  danger,  in  treating 
cases  where  there  is  any  form  of  degeneration,  infection,  or  malignant  disease,  of 
greatly  aggravating  the  complicating  process.  Radiation  when  apphed  im- 
properly to  fibroid  tumors  may  cause  degeneration,  necrosis,  and  inflammation,, 
so  that  it  must  be  used  only  by  the  most  experienced. 

After  the  menopause  bleeding  always  means  some  form  of  degeneration  or 
malignancy,  so  that  radiation  should  not  be  used  at  that  period  of  life. 

The  work  of  Kelly  with  radium  in  treating  myomata  has  been  especially  noteworthy.  His 
method  of  treatment  is  to  introduce  large  amounts  of  radium  into  the  uterine  canal  with  com- 
paratively short  exposure.  He  is  able  to  produce  amenorrhea  in  every  case,  and  in  many 
instances  a  great  reduction  and  even  disappearance  of  the  tumor.  In  the  case  of  yoimg 
women,  by  proper  regulation  of  the  dosage  he  can  relieve  menorrhagia  without  causing  com- 
plete amenorrhea.  Kelly  beheves  that  with  improved  technic  it  will  be  possible  to  reheve 
every  patient  of  hemorrhage  and  in  9  cases  out  of  10  to  do  away  with  the  tumor. 

Myomectomy  and  Hysterectomy. — The  surgical  treatment  of  uterine  myo- 
mata consists  either  in  the  enucleation  of  the  tumor,  myomectomy,  so-called,  or 
in  the  removal  of  the  uterine  body  by  a  supravaginal  hysterectomy. 


326  GYNECOLOGY 

Small  tumors  that  are  met  with  incidentally  during  a  pelvic  operation  should 
always  be  removed  by  myomectomy  as  a  routine,  unless  they  are  so  numerous 
or  deep-seated  that  this  operation  is  not  feasible. 

It  is  often  possible  to  enucleate  symptom-giving  tumors  of  considerable  size, 
and  the  question  not  infrequently  arises  as  to  which  operation  is  advisable.  This 
question  must  be  decided  very  much  as  is  the  question  of  conservatism  or  radical- 
ism in  chronic  pelvic  inflammation.  One  must  first  weigh  the  comparative 
merits  of  the  two  operations.  If  the  myoma  is  of  considerable  size  and  not  well 
pedunculated,  a  myomectomy  is  a  bloodier  and  more  difficult  operation  than  hys- 
terectomy. The  immediate  convalescence  from  extensive  myomectomy  opera- 
tions is  apt  to  be  very  stormy,  while  that  from  hysterectomy  is  unusually  good. 
Moreover,  the  removal  of  one  or  more  fibroids  from  the  wall  of  the  uterus  does 
not  insure  against  the  development  of  others  at  some  later  date.  In  young 
.women  the  chances  of  recurrence  are  very  considerable.  Myomectomy  opera- 
tions, owing  to  the  exposure  of  wound  edges  and  suture  knots,  are  more  often 
followed  by  postoperative  adhesions  than  are  hysterectomy  operations.  Thus, 
it  will  be  seen  that  myomectomy  has  certain  disadvantages  which  often  make  the 
procedure  inadvisable.  There  are,  however,  circmnstances  under  which  the 
operation  must  be  performed  if  it  is  surgically  possible  to  do  so.  The  most  im- 
portant indications  for  its  use  are  in  young  women  who  wish  to  bear  children, 
and  in  those  who  for  sentimental  reasons  prefer  the  ill  chances  of  a  myomectomy 
to  the  loss  of  pelvic  organs.  Women  in  the  child-bearing  period  who  have  had  a 
myomectomy  performed  should  be  periodically  examined  until  after  the  meno- 
pause. 

Most  fibroids  that  require  operation  are  best  treated  by  a  supravaginal  hys- 
terectomy by  the  abdominal  route.  The  abdominal  route  has  so  many  advantages 
over  the  vaginal  that  the  question  hardly  needs  discussion.  It  may  be  said,  how- 
ever, that  the  chief  advantage  of  the  former  is  that  it  is  possible  to  secure  a  much 
more  efficient  postoperative  pelvic  support,  a  point  that  far  outweighs  all  other 
considerations. 

A  supravaginal  operation  is  preferable  to  a  complete  hysterectomy,  partly 
because  it  is  a  simpler  and  safer  operation,  and  partly  because  by  leaving  the 
cervix  better  pelvic  support  can  be  secured. 

The  only  advantage  that  a  complete  hysterectomy  has  over  supravaginal 
amputation  is  the  avoidance  of  a  possible  future  carcinoma  of  the  remaining 
cervical  stump.  This  complication  does  occur,  but  it  is  extremely  rare.  It  is 
safe  to  say  that  if  a  complete  hysterectomy  were  performed  in  every  case  as  a 
routine  the  increased  operative  mortality  would  be  considerably  greater  than 
the  incidence  of  cancer  following  supravaginal  amputation. 

The  technic  of  supravaginal  hysterectomy  is  described  in  detail  on  page  7,13. 
The  chief  points  to  aim  for  in  performing  the  operation  are  to  secure  permanent 
pelvic  support  and  to  avoid  the  possibility  of  postoperative  adhesions.  If  these 
two  objects  are  attained  the  after-results  of  hysterectomy  for  fibroids  are  excel- 


NEW   GROWTHS  327 

lent,  and  are  especially  remarkable  in  those  cases  where  there  have  been  associ- 
ated nervous  disturbances. 

The  question  of  leaving  in  one  or  both  ovaries  when  possible  is  one  about 
which  there  is  considerable  disagreement.  It  is  doubtful  if  leaving  in  ovarian 
tissue  does  very  much  good. 

Polypoid  myomata  are  removed  per  vaginam.  If  they  have  a  firm  pedicle 
they  can  be  removed  with  blunt-tipped  scissors,  preferably  under  an  anesthetic, 
as  the  bleeding  is  sometimes  troublesome.  Some  of  the  necrotic  myomata  can 
be  removed  by  the  finger  without  anesthesia,  a  point  that  is  useful  to  remember 
in  treating  elderly  women,  in  whom  these  necrotic  fibroids  very  frequently  appear. 

ADENOMYOMA 

Adenomyomata  constitute  a  special  type  of  uterine  fibroids.  They  are 
distinguished  from  the  ordinary  myomata  by  the  diffuse  manner  in  which 
they  grow  in  the  uterine  wall,  and  by  their  containing  embedded  in  the  myo- 
matous tissue  numerous  gland-like  structures.  These  glands  are  lined  by  epi- 
thelium very  similar  to,  and  probably,  for  the  most  part,  identical  with,  that  of 
the  endometrium,  while  immediately  surrounding  the  glands  is  a  cytogenous 
connective  tissue  like  that  of  the  endometrial  stroma. 

The  origin  of  the  adenomyomata  is  a  matter  of  much  scientific  interest. 
As  a  result  of  the  investigations  of  von  Recklinghausen,  it  was  believed  for  a 
time  that  they  all  develop  from  rests  of  the  Wolffian  body,  von  Recklinghausen 
demonstrated  structures  in  some  of  his  specimens  resembling  the  convoluted 
tubules  and  glomeruli  of  the  kidney.  Later  researches,  especially  by  R.  Meyer, 
Cullen,  and  Opitz,  have  shown  that  in  most  instances  the  glandular  elements 
are  developed  from  and  connected  with  the  glands  of  the  mucosa.  Meyer  has 
also  shown  that  in  some  of  the  small  subserous  tumors  the  epithelial  structures 
are  derived  from  the  peritoneal  epithelium  of  the  surface  of  the  uterus.  It  is 
conceded  that  only  one  form  of  adenomyoma,  that  which  grows  in  the  parame- 
trium, is  probably  derived  from  embryonal  rests. 

The  adenomyomata,  for  the  most  part,  develop  in  the  posterior  wall  of  the 
uterus,  more  commonly  near  the  uterine  horns.  They  may,  however,  grow  in 
any  part  of  the  uterus  and  even  rarely  in  the  cervix.  Occasionally  they  form 
polypoid  tumors  in  the  uterine  canal.  They  do  not  attain  large  dimensions, 
rarely  reaching  a  size  greater  than  that  of  an  orange.  On  account  of  the  diffuse 
nature  of  their  growth  it  is  often  difficult  to  distinguish  the  boundary  line  be- 
tween tumor  and  uterine  wall,  especially  if  the  tumor  is  located  near  glandular 
tissue,  as  in  the  case  of  adenomyomata  at  the  uterine  horns.  In  fact,  many  of 
the  so-called  tumors  of  this  region  are  pronounced  by  Meyer  not  true  tumors 
at  all,  but  inflammatory  hypertrophy  of  the  uterus,  a  condition  to  which  he 
gives  the  name  of  "adenomyositis."  It  has  also  been  shown  that  adenomyo- 
mata are  frequently  associated  with,  and  probably  caused  by,  chronic  pelvic 
inflammatory  processes,  in  which  tuberculosis  plays  an  important  part. 


328 


GYNECOLOGY 


The  adenomyomata  are  not,  as  a  rule,  of  great  clinical  importance.  They 
do  not  often  grow  to  a  size  large  enough  to  produce  serious  symptoms  unless 
the  tumor  is  a  polypoid  growth  into  the  uterine  canal. 

The  symptoms  of  adenomyomata  are  menorrhagia  and  menstrual  pain 
referred  to  the  uterus.  Cullen,  who  has  made  an  exhaustive  study  of  these 
tumors,  regards  the  clinical  diagnosis  of  the  condition  as  not  difficult. 


Fig.  98. — Adenomyoma. 
High  power.     Sections  of  four  glands  are  seen,  lined  by  a  single  layer  of  epithelial  cells.     These 
lie  in  a  connective-tissue  stroma  like  that  of  the  endometrium.     The  whole  is  surrounded  by  myo- 
matous tissue  in  which  are  a  few  mononuclear  leukocytes. 

The  adenomyomata  have  no  special  disposition  to  carcinomatous  change, 
though  this  does  occur  in  rare  instances. 


SARCOMA   OF   THE   UTERUS 

Sarcoma  of  the  uterus  is  far  less  common  than  uterine  cancer,  the  rela- 
tive proportion  of  frequency  being  about  1  to  40.  These  tumors  always  arise 
from  the  connective  tissue  of  the  uterus,  and  may  have  their  origin  either  in  the 
connective  tissue  of  the  myometrium  or  in  that  of  the  mucous  membrane. 
They  are  divided  into  two  important  classes,  according  to  these  two  points  of 


NEW    GROWTHS 


329 


origin.  Those  that  develop  in  the  myometrium  almost  invariably  represent  a 
malignant  change  in  a  pre-existing  fibromyoma — so-called  malignant  degenera- 
tion of  fibroids.  This  type,  termed  myosarcoma,  is  stated  by  Meyer  to  be  far 
more  common  than  that  which  arises  from  the  mucous  membrane. 

Myosarcoma  of  the  uterus,  for  the  most  part,  is  an  affection  of  middle  age, 
the  highest  incidence  occurring  at  about  fifty.  Sarcoma  from  the  mucous 
membrane  appears  relatively  earlier,  the  youngest  case  reported  by  Doderlein 
being  five  years,  while  the  youngest  case 
of  myosarcoma  reported  was  twenty. 

The  etiology  of  sarcoma  of  the  uterus 
is  quite  obscure. 

Sarcoma  of  the  Mucous  Membrane. — 
Macroscopically,  sarcoma  of  the  mucous 
membrane  may  be  diffuse  or  polypoid. 
In  the  polypoid  form  masses  of  peduncu- 
lated tumors  become  extruded  through 
the  cervical  canal,  and  either  slough  off 
spontaneously  or  are  removed  by  opera- 
tion, only  to  appear  again.  These  con- 
stantly recurring  tumors  are  sometimes 
called  recurrent  fibroids  until  a  micro- 
scopic examination  reveals  the  true 
nature  of  the  growth  (Fig.  99).  Where 
this  type  of  sarcoma  springs  from  the 
mucosa  of  the  cervix  the  vagina  be- 
comes filled  with  a  mass  of  grape-like 
polyps,  which  eventually  protrude 
through  the  introitus  into  the  outer 
world.  The  tumor  under  these  condi- 
tions is  commonly  called  a  grape-mole 
or  sarcoma  botryoides. 

Diffuse  sarcoma  of  the  endometrium 
spreads  into  the  wall  of  the  uterus 
peripherally  in  the  same  manner  as  an 
inverting  adenocarcinoma  of  the  body. 

Myosarcoma. — Sarcomatous  degeneration  of  fibroid  tumors — myosarcoma — 
usually  starts  near  the  center  of  the  growth.  It  may  appear  as  a  sharp  1}^  defined 
nodule  or  it  may  spread  diffusely  in  the  surrounding  tissue.  Various  forms  of 
degeneration  are  apt  to  take  place,  so  that,  macroscopically,  the  sarcomatous 
portion  of  the  tumor  is  sometimes  distinguished  from  the  normal  tissue  by  dis- 
colored appearances,  necrosis,  or  accumulation  of  fluid. 

Histology. — The  cells  of  which  the  uterine  sarcomata  are  made  up  are  con- 
siderably varied.     Meyer  divides   the  growths  into   muscle-cell  sarcoma    (in 


Fig.  99. — Grape  Sarcoma,  or  Sarcoma  Bot- 
ryoides. 
The  vagina  is  seen  crowded  with  grape- 
like  masses  of  the  growth.      (Copied  from   a 
drawing  in  Kiistner's  Handbuch.) 


330 


GYNECOLOGY 


which  muscle  cells  and  sarcoma,  cells  are  mixed),  spindle-cell  sarcoma,  and  round- 
cell  sarcoma.  The  cells  may  be  of  all  kinds  and  sizes.  Sarcomata  of  the  endo- 
metrium are  chiefly  characterized  by  round  cells. 

The  latter  type  of  sarcoma  (especially  the  diffuse  kind)  is  sometimes  differen- 
tiated with  difficulty  from  adenocarcinoma  of  the  body,  which  in  the  advanced 
stages  loses  its  glandular  characteristics,  the  appearance  and  arrangement  of 
the  cells  appearing  quite  similar  to  round-cell  sarcoma.  On  the  other  hand, 
the   cells   of   diffuse   sarcoma  of  the   endometrium   may  assume  an  alveolar 


Fig.  100. — Sarcoma  of  the  Cervix. 
Low  power.  This  drawing  shows  the  sharp  line  of  demarcation  between  the  growth  on  the 
left  and  the  cervical  stroma  on  the  right.  The  latter  consists  of  connective  tissue  with  a  few 
bundles  of  muscle  scattered  through  it.  The  former  consists  of  a  homogeneous  mass  of  cells  very 
nearly  the  same  size,  having  circular  vesicular  nuclei.  There  is  very  little  stroma  between  the 
masses,  and  they  are  traversed  by  a  fine  network  of  capillaries,  as  can  be  seen  in  the  drawing.  In 
the  center  is  a  blood-vessel  running  into  the  tumor  tissue  from  the  cervical  stroma. 


arrangement  which  closely  resembles  an  adenocarcinoma.  This  is  sometimes 
called  "adenosarcoma."  In  some  cases  there  is  a  rich  development  of  blood- 
vessels or  lymph  elements,  and  the  tumors  are  termed  "angiosarcoma"  or 
''lymphosarcoma."  Melanosarcoma  of  the  uterus  has  been  described.  Cystic 
degeneration  of  the  tumors  has  led  to  the  designation  "cystic  sarcoma." 

It  is  possible  for  sarcoma  and  carcinoma  to  coexist  in  the  same  uterus. 

Diagnosis. — An  accurate  clinical  diagnosis  of  sarcoma  of  the  uterus  is,  in 
the  majority  of  cases,  very  difficult  to  make.     In  the  polypoid  type,  where  the 


NEW   GROWTHS  331 

tumors  present  in  the  vagina,  the  removal  of  a  section  for  microscopic  examina- 
tion can  easily  be  done.  The  so-called  recurrent  fibroids  are  almost  pathog- 
nomonic of  sarcoma,  but  the  specimens  removed  or  expelled  should  receive 
microscopic  examination.  In  the  less  obvious  forms  of  sarcoma  the  diagnosis 
is  very  blind,  and  is  usually  not  definitely  made  except  by  the  microscope, 
after  operation  or  autopsy.  There  are,  however,  certain  symptoms  which  msiy 
lead  to  suspicion  of  sarcoma,  and  of  these  uterine  bleeding  is  the  most  important. 
In  children  before  puberty,  bleeding  from  the  vagina,  if  precocious  menstruation 
is  excluded,  must  be  regarded  with  grave  concern,  for  it  is  apt  to  indicate  the 
presence  of  uterine  or  vaginal  sarcoma.  In  later  life  all  bleeding  and  sloughing 
myomatous  polyps  should  receive  searching  microscopic  examination.  Diffuse 
sarcoma  of  the  uterine  mucosa  occurring  during  menstrual  life  presents  practi- 
cally the  same  symptoms  as  adenocarcinoma  of  the  body,  chiefly  metrorrhagia 
and  foul  discharge.  The  diagnosis  should  be  made  in  the  same  way,  namely, 
by  removal  of  a  specimen  for  microscopic  study,  preferably  under  an  anesthetic, 
and  preliminary  to  operation. 

Where  the  sarcoma  represents  a  malignant  degeneration  of  a  mj^oma  the 
diagnosis  can  rarely  be  made  positively.  ]Many  times  these  sarcomata  are 
discovered  only  during  the  routine  examination  to  which  all  fibroids  should  be 
subjected.  During  menstrual  life  menorrhagia  and  rapid  increase  of  a  myoma- 
tous uterus  give  warning  of  mahgnant  degeneration,  but  these  sj^mptoms  are, 
of  course,  not  pathognomonic,  as  fibroids  often  take  on  sudden  and  rapid  in- 
crease without  the  stimulus  of  malignant  change.  After  the  menopause  the 
appearance  of  blood  and  sudden  enlargement  of  a  long-existing  myoma  are 
very  suggestive  signs  of  sarcomatous  change,  but  thej-  may  also  be  caused  bj' 
other  forms  of  degeneration. 

The  appearance  of  ascites,  together  with  rapid  growth  of  a  fibroid  tumor, 
is  a  warning  of  sarcomatous  change,  for  it  rarely  occurs  in  connection  with  non- 
malignant  fibroids.  Loss  of  weight  and  cachexia  are  also  important  symptoms 
suggestive  of  sarcoma. 

Estimates  of  the  frequency  with  which  sarcomatous  degeneration  takes  place 
in  fibroids  varj"  from  less  than  1  per  cent,  to  over  10  per  cent.  This  wide 
difference  is  due  to  errors  in  microscopic  diagnosis,  for  in  many  instances  rapidh^ 
growing  myomatous  tissue  resembles  sarcoma  so  closelj^  that  a  correct  differen- 
tial diagnosis  can  be  made  only  by  the  most  expert.  The  true  incidence  of  sarco- 
matous degeneration  of  uterine  fibroids  is  probably  between  1  and  2  per  cent. 

Sarcoma  of  the  uterus  has  a  much  greater  tendency  to  metastasize  to  distant 
■parts  of  the  body  than  does  cancer,  either  of  the  body  or  of  the  cervix,  and  for 
this  reason  it  must  be  regarded  as  especially  malignant.  The  tendency  to 
metastadze  varies  somewhat  according  to  the  special  type  of  sarcoma.  The 
most  dangerous  form  is  the  diffuse  sarcoma  of  the  endometrium  which  metas- 
tasizes ver^'  early.  Somewhat  less  mahgnant  is  the  polypoid  type,  while  the 
most  favorable  is  the  sarcoma  of  uterine  myomata. 


332  GYNECOLOGY 

This  last-named  group  is  apt  to  be  very  treacherous,  however,  for  some- 
times a  small  and  inoffensive  localized  area  within  a  myoma  may  be  followed 
after  removal  by  extensive  metastases  and  death. 

The  treatment  of  sarcoma  of  the  uterus  consists,  if  the  case  is  operable,  in  a 
total  extirpation  of  the  uterus,  preferably  by  the  Wertheim  method. 

In  inoperable  cases  there  is  not  much  that  can  be  done.  Radium  and  x-ray 
treatment  is,  for  the  most  part,  ineffectual,  and  is  positively  contraindicated 
in  degenerated  myomata,  for  by  this  means  the  malignant  disease  may  often 
be  stimulated  to  new  activity. 

CERVICAL   POLYPS 

Cervical  mucous  polyps  occur  with  extraordinary^  frequency.  They  are 
seen  most  commonly  in  women  after  forty,  though  they  may  appear  earlier. 
They  are  very  frequent  after  the  menopause. 


..^;^~-„  /f^i-#3^,;»«a^^^ 

/j--::^c                   :    :    ~        '                  '~^^ 

=  '  '■                       ,-    ■                       "'■■ 

'   i^^ 

/'/'                     ~    ~-"   , 

'        ~ 

V     .-■"'"              -      •„  \ 

<~: 

- 

\                                            .,            -^              ^ 

-     1' 

~"--  -  -       •'                            ■  -■.      '      ,_ 

^ 

■■^ 

^..C^^^,      -"' 

^f.C.^M-V:::F. 

Fig.  101. — Ceevical  Polyp. 
Cross-section  of  a  polyp.     The  epithelium  covering  the  polyp  is  of  the  stratified  squamous  va- 
riety, showing  that  this  part  of  the  polyp  lay  in  the  vagina.    The  spaces  are  dilated  glands  lined  by  a 
single  layer  of  cylindric  epithelium  similar  to  that  of  the  cervical  canal,  where  the  polyp  originated. 
The  stroma  consists  of  connective  tissue  with  a  few  muscle  bundles  in  it. 

The  cervical  polyp  represents  a  hypertrophy  of  the  mucous  membrane  of 
the  endocervix  and  contains  all  the  elements  of  that  structure.  It  usually  has 
a  slender  pedicle,  so  that  the  polyp  can  easily  be  plucked  off.     Sometimes  the 


NEW   GROWTHS 


333 


polyp  is  sessile,  with  a  broad  base.  These  growths  never  reach  a  large  size  and 
are  more  often  multi'ple  than  single.  They  are  of  a  bright  red  or  purple  color, 
and  can  usually  be  felt  by  the  examining  finger  as  soft  movable  bodies  at  the 
ring  of  the  external  os.  They  may  grow  in  any  portion  of  the  cervical  canal. 
When  one  is  seen  extruding  at  the  external  os  there  are  usually  others  higher 
up  in  the  canal. 

They  are  composed  of  hypertrophied  cervical  mucous  membrane,  the  glands 
being  dilated  and  cystic,  filled  with  a  clear  mucus.  When  grasped  with  an 
instrument  they  easily  rupture  and  collapse.     These  small  tumors  have  no 


Fig.  102.- — Mucous  Polyp  of  the  Endometrium. 


tendency  to  become  mahgnant.  They  are,  however,  by  no  means  harmless 
and  are  sometimes  of  considerable  clinical  importance. 

Symptoms. — The  chief  symptom  is  bleeding.  Polyps  may  evidently  exist 
for  long  periods  of  time  without  making  themselves  known.  As  a  rule,  the 
bleeding  is  rather  mild  in  character.  There  is  apt  to  be  an  increase  of  menstrual 
flow  with  slight  signs  of  blood  between  the  periods.  If  the  menopause  is  past, 
the  bleeding  usually  shows  as  a  slight  staining  on  the  underclothing.  Some- 
times, however,  even  a  small  polyp  may  be  the  cause  of  profuse  and  exhausting 
hemorrhages.  Patients  not  infrequently  acquire  a  pronounced  secondary 
anemia  from  their  presence. 

Mucous  polyps  often  set  up  a  very  persistent  leukorrheal  discharge.     They 


334  GYNECOLOGY 

easily  become  eroded  and  infected  and  maintain  an  inflammation  of  the  endo- 
cervical  mucous  membrane.  Often  leukorrhea  is  the  only  symptom  of  their 
presence. 

The  diagnosis  of  cervical  polyps  is  very  important,  for  they  produce  symp- 
toms very  like  those  of  mahgnant  disease.  In  most  cases  they  can  be  felt  and 
seen,  even  if  they  are  growing  part  way  up  the  cervical  canal,  for  they  usually 
cause  the  external  os  to  be  more  patulous  than  normal.  In  fact,  in  the  presence 
of  the  above-named  symptoms  an  abnormally  patulous  os  leads  one  to  suspect 
polyps,  even  if  they  are  not  at  first  apparent.  The  macroscopic  appearance 
of  a  pedunculated  polyp  is  quite  characteristic  and  could  rarely  be  confused 
with  anything  else.  The  sessile  variety  which  grow  well  up  in  the  cervix  might 
suggest  cancer.  Microscopically,  the  picture  is  invariably  that  of  hyper- 
trophied  endocervical  mucous  membrane.  The  larger  polyps  may  sometimes 
be  mistaken  for  degenerated  polypoid  myomata  and  should  be  carefully  differ- 
entiated from  them  by  the  microscope,  because  the  latter  may  sometimes  be  ma- 
hgnant (adenomyomata,  ''recurrent"  fibroid).  The  diagnosis  of  cervical  polyp 
cannot  always  be  made  by  digital  examination  and  inspection,  but  may  require 
anesthesia  and  an  intra-uterine  examination.  With  symptoms  of  irregular 
bleeding  the  possibility  of  cervical  polyps  must  not  be  overlooked,  for  it  is 
very  easy  to  miss  them  during  an  intra-uterine  examination  if  the  upper  part 
of  the  cervical  canal  is  not  carefully  investigated  with  curet  and  polyp  forceps. 

The  treatment  of  cervical  polyps  is  always  removal.  The  pedunculated 
polyps  at  the  external  os  can  easily  be  removed  through  a  speculum  by  snipping 
them  off  with  scissors,  and  it  is  a  temptation  to  do  this  in  the  office.  It  is 
always  better  to  advise  anesthesia  and  a  complete  intra-uterine  examination, 
for  in  the  majority  of  cases  one  or  more  small,  beginning  polyps  can  be  found 
higher  up  in  the  cervix  in  addition  to  the  one  that  is  apparent.  It  is  also  im- 
portant to  curet  thoroughly  the  canal  of  the  cervix,  for  in  most  cases  there  is  an 
associated  endocervicitis  which  is  very  apt  to  persist  after  the  removal  of  the 
polyp.  As  a  rule,  cutting  off  these  growths  causes  very  little  bleeding.  The 
sessile  variety  sometimes  needs  dissection  and  the  placing  of  two  or  three  fine 
catgut  sutures  in  the  wound. 

Well-defined  mucous  -polyps  of  the  endometrium  are  less  common  than  those 
from  the  cervical  mucosa.  Their  formation,  symptomatology,  and  treatment 
are  the  same.  It  is  an  easy  matter  to  miss  them  during  an  exploratory  curetage 
of  the  uterine  canal,  and  for  that  reason  it  is  always  advisable  in  this  operation 
to  search  the  canal  with  placenta  forceps. 

CANCER   OF   THE   CERVIX 

Cancer-  starting  in  the  cervix  of  the  uterus  must  be  studiously  differentiated 
from  that  which  originates  in  the  body'  The  two  forms  are  quite  distinct, 
both  histologically  and  chnically,  a  fact  which  serves  still  further  to  emphasize 


NEW    GROWTHS 


335 


that  the  cervix  and  body  of  the  uterus  are  to  be  regarded  as  two  independent 
organs  that  differ  widely  from  each  other  in  their  pathologic  and  physiologic 
processes. 

Pathology, — Cancer  of  the  cervix  when  it  comes  under  observation  usually 
appears  as  a  squamous-cell  carcinoma.  In  its  incipiency,  however,  the  growth 
presents  certain  differences,  according  to  the  particular  part  of  the  cervix  in 
which  the  disease  has  its  origin.  It  is  necessary  to  remember  that  the  epi- 
thelium of  the  cervix  is  divided  into  two  parts,  that  which  covers  the  vaginal 
portion  and  that  which  extends  from  the  external  to  the  internal  os,  the  so-called 


;cxv\cer-\- 


:j  Vc\<^vr\cv. 


Nv:^.< 


Fig.  103. — Everting  Cancer  of  the  Cervix. 
In  this  case  the  disease  has  originated  in  the  posterior  lip  of  the  portio  and  is  growing  in  cauli- 
flower-like masses  toward  the  vagina.     There  is  only  moderate  invasion  of  the  cervical  wall.     It  can 
readily  be  seen  that  this  form  is  less  treacherous  than  the  inverting  type. 


endocervix.  The  epithelium  covering  the  vaginal  portion  is  really  modified 
epidermis,  and  consists  of  layers  of  squamous  cells  like  those  of  the  skin,  but 
without  hair-follicles,  sebaceous  or  sweat  glands.  The  squamous  epithelial 
cells  just  above  the  external  os  merge  into  true  mucous  cells,  which  hne  the 
surface  both  of  the  endocervix  and  the  arborescent  glands  that  branch  from 
the  endocervix.  In  a  nulliparous  woman  under  normal  conditions  the  endocervix 
is  entirely  concealed  and  well  protected  by  the  contour  of  the  vaginal  portion. 
When  the  cervix  has  been  lacerated  the  endocervix  tends  to  evert,  and  appears 
redder  and  more  roughened  than  the  squamous  epithelium  of  the  vaginal  por- 


336 


GYNECOLOGY 


tion.  This  appearance  has  led  to  its  being  called  an  erosion  or  ulceration. 
Although  true  erosion  may  occur,  the  condition  usually  is  one  of  eversion  or 
ectropion. 

Cervical  cancer  may  originate  in  the  squamous  epithelium  of  the  vaginal 
portion,  or  in  the  transition  epithelium  of  the  everted  area,  or  in  the  fully 
developed  cylinder  mucous  epithelium  higher  up  in  the  endocervix.  If  the 
cancer  starts  from  the  epithelium  of  the  vaginal  portion  it  begins  as  a  typical 
squamous  cell  carcinoma  or  epithelioma  with  large  polyhedral  cells  and  forma- 
tion of  cancroid  pearls.     If  the  cancerous  process  starts  in  the  everted  mucous 


,\J\c€ratvow 


JriG.  104.- — Inverting  Cancer  of  the  Cervix. 
In  this  case  the  growth  is  invading  the  walls  of  the  cervix  with  little  tendency  to  extend  outward 
into  the  vagina.     In  this  type  there  is  an  earlier  invasion  of  the  parametrium.     It  can  be  seen  from 
the  drawing  that  the  disease  might  escape  detection  by  the  examining  finger.     This  form  of  the  disease 
is  especially  treacherous. 

membrane  or  in  the  endocervical  canal,  the  structure  of  the  epithelial  growth  is 
at  first  adenoid,  but  this  characteristic  is  usually  soon  lost  and  the  cells  grow 
in  solid  masses,  approaching  the  squamous  cell  type.  As  most  cases  of  cancer 
of  the  cervix  are  well  advanced  before  they  come  to  examination,  it  is  usually 
difficult  to  tell  from  the  microscopic  appearance  where  the  disease  started. 
For  this  reason  nearly  all  cancers  of  the  cervix  are  diagnosed  as  squamous  cell 
carcinomata  or  epitheliomata. 

Occasionally,  but  not  often,  the  adenoid  type  persists  in  a  growth  originat- 
ing from  the  endocervix  and  the  growth  remains  as  a  true  adenocarcinoma. 


NEW   GROWTHS 


337 


It  is  important  to  bear  in  mind  the  points  from  which  cervical  cancer  may 
start,  as  the  course  of  the  disease  varies  somewhat  according  to  the  place  of 


\ 


A 


Fig.  105. — Adenocarcinoma  of  the  Cervix. 
Very  low  power.  Section  of  the  whole  uterus.  At  the  bottom  on  each  side  is  the  A-aginal  wall. 
The  outside  of  the  cervix  appears  normal.  On  the  left,  extending  the  whole  length  of  the  cervical 
canal,  is  the  growth,  invading  the  stroma  of  the  cervix.  More  of  it  can  be  seen  at  the  internal  os  on  the 
right.  This  illustrates  especially  the  importance  of  curetage  for  diagnosis,  as  this  growth  could  not 
be  seen  on  inspection  of  the  cervix. 


origin.     Thus,  cancer  beginning  in  the  epithehum  of  the  vaginal  portion  grows 
outward  in  papillary  excrescences  until  a  characteristic  cauliflower  mass  is  formed. 


338 


GYNECOLOGY 


It  has  little  tendency  to  extend  toward  the  body  of  the  uterus,  and  invades  the 
parametrium  and  regional  lymph-glands  relatively  later  than  does  cancer  of  the 
endocervix.  On  the  other  hand,  it  has  a  greater  tendency  to  invade  the  vaginal 
wall  and  extend  to  the  bladder. 

Cancer  of  the  endocervix  may  grow  outward  in  a  papillary  form  like  that 
from  the  portio,  especially  if  it  originates  in  the  everted  mucous  membrane  of  a 
lacerated  cervix.  It  has,  however,  a  special  tendency  to  become  what  is  called 
"invertent";  that  is  to  say,  it  grows  inward  toward  the  cervical  wall  and  para- 
metrium. The  process  may  continue  for  a  considerable  time  without  giving 
external  evidence  of  its  presence.     It  reaches  the  parametrium  earher  than  does 


v.on 


Fig.  106. — -Advanced  Cancer  of  the  Cervix. 

In  this  case  the  disease  has  invaded  the  whole  of  the  cervical  walls  and  is  extending  into  the  walls  of  the 

vagina  and  bladder.     The  crater  represents  the  condition  after  curetment  and  cauterization. 


cancer  of  the  portio,  and  has  a  relatively  greater  tendency  to  metastasize  to  the 
regional  lymph-glands.  It  may  also  invade  the  vaginal  wall  by  extension  in 
the  subepithehal  connective  tissue,  causing  a  thickening  and  induration  of  the 
wall  without  disturbing  the  epithelial  covering. 

It  will  be  seen,  therefore,  that  this  form  of  cervical  cancer  is  especially 
treacherous,  in  that  it  may  progress  to  an  advanced  stage  without  giving  warning 
of  its  presence. 

In  the  majority  of  cases  the  disease  has  so  far  advanced  before  the  patient 
appears  for  examination  that  it  is  impossible  to  tell,  either  from  gross  inspection 
or  microscopic  examination,  the  location  in  the  cervix  from  which  the  growth 


NEW    GROWTHS 


339 


originally  started.     In  the  following  discussion  the  various  types  will  not  be 
distinguished,  but  will  be  included  together  under  the  term  "cervical  cancer." 

Incidence. — Cancer  of  the  cervix  appears  most  commonly  between  the  ages 
of  forty  and  fifty.  In  a  series  of  6071  cases  collected  by  one  investigator  (Kob- 
lanck)  33.7  per  cent,  occurred  between  thirty  and  forty,  and  24  per  cent,  between 
thirty  and  sixty.  Occasionally  cases  are  seen  later  than  sixty  and  earlier  than 
thirty.  In  our  own  experience  the  youngest  case  has  been  twenty-five.  Craigin 
has  reported  a  case  of  cancer  of  the  cervix  in  a  girl  of  eighteen. 


\Jt«.t>.YveVesSe)<; 


V(.ip.G»'<co5€S^ 


Fig.  107. — Cancer  of  the  Cervix. 
The  drawing  is  from  a  specimen  removed  by  the  Wertheim  extended  method.'-     The  uterus 
has  been  partly  opened  to  show  the  extent  of  the  disease.     On  the  sides  can  be  seen  the  parametria! 
tissue  and  uterine  vessels.     The  margin  of  vaginal  wall  that  must  be  removed  is  also  shown. 

There  is  a  question  if  cancer  of  the  uterus  is  as  common  in  this  country  as 
in  Europe.  The  statistics  of  the  Continental  operators  are  so  enormously  larger 
than  are  those  of  our  surgeons  who  practise  in  populous  districts  that  it  seems 
as  if  the  cases  must  be  fewer  in  number  here.  This  applies  not  only  to  the 
number  of  operable  cases,  but  to  the  total  number  of  cases  seen.  It  is  reason- 
ably certain  that  cancer  of  the  uterus  is  not  on  the  increase  in  this  country,  and 
more  recent  statistics  show  that  there  is  no  definite  increase  of  the  disease  in 
Europe. 

Etiology. — Cancer  of  the  cervix  is  distinguished  among  other  malignant 
neoplasms  of  the  body  by  having  a  very  constant  and  definite  etiologic  factor 
in  its  histogenesis,  in  that  it  occurs  almost  exclusively  in  cervices  that  have  had 
some  inflammatory  or  traumatic  lesion,  usually  the  result  of  childbirth.     It  is 

'  Operation  by  Dr.  H.  T.  Hutchins  at  the  Free  Hospital  for  Women. 


340 


GYNECOLOGY 


.^  '•  .:> 


',','<..,  'f*^  .«  .^  '  <tj  fe__,    ,; 


Fig.  108. — Squamous  Carcinoma  of  the  Cervix. 
High  power.     Most  of  the  tissue  consists  of  large  epithelial  cells  which  vary  greatly  in  size, 
and  are  infiltrated  with  a  few  round  cells.     A  few  strands  of  stroma  are  seen  thickly  infiltrated  with 
round  cells.     Between  these  two  tissues  there  is  no  basement-membrane,  and  the  typical  basal  layer 
of  cells  found  in  stratified  squamous  epithelium  is  missing. 

variously  estimated  that  from  96.5  to  98  per  cent,  of  women  with  cancer  of  the 
cervix  have  had  children,  and  that  the  greater  majority  have  been  multiparous. 


NEW   GROWTHS 


341 


It  has  been  a  common  idea  that  the  carcinomatous  process  is  especially 
favored  by  the  scar-tissue  that  forms  in  an  old  laceration.  One  theory  sug- 
gests that  after  a  cervical  tear  epithelial  cells  become  included  in  the  submucous 
tissue,  and  that  toward  the  time  of  the  climacteric,  when  the  stroma  begins  to 
lose  its  power  of  resistance,  the  cell  inclusion  has  an  opportunity  to  grow  wild. 
Another  theory  is  that  the  lesion  of  the  external  os  deprives  the  cervical  mucous 
membrane  of  an  important  means  of  protection.     Not  only  is  the  dehcate 


Fig.  109.- — Squamous  Carcinoma  of  the  Cervix. 
High  power.  On  the  left  of  the  picture  is  seen  a  trabeculum  of  the  stroma  of  the  cer^dx.  The  rest 
of  the  tissue  consists  of  epithelial  cells  which  show  no  definite  formation,  which  have  lost  the  layer 
of  basal  cells  seen  in  normal  stratified  squamous  epithelium,  and  which  individually  are  large,  irregular 
in  shape,  and  have  nuclei  that  vary  greatly  in  size.  Mitotic  figures  are  seen  in  various  stages,  especi- 
ally near  the  top. 


membrane  exposed  directly  to  continual  injury,  but  the  mucus,  which  in  the 
intact  cervix  acts  as  a  kind  of  protective  plug,  now  pours  directly  into  the 
vagina. 

Whatever  theory  is  right,  there  is  no  doubt  that  cervices  which  show  an 
ectropion  of  the  cervical  mucous  membrane,  or  an  erosion  on  the  external  lips, 
have  a  special  predisposition  to  cancer.  The  most  common  cause  for  ectropion 
and  erosion  is  laceration  of  the  cervix.     We  do  find,  however,  erosions  in  nullip- 


342  GYNECOLOGY 

arous  women,  sometimes  in  virgin  women,  where  the  cause  is  doubtful.  Doubt- 
less the  few  cases  of  cancer  that  occur  in  nulliparous  women  originate  in  erosions 
of  this  kind. 

An  argument  that  is  sometimes  advanced  against  the  traumatic  theory 
of  the  etiology  of  cervical  cancer  is  the  fact  that  in  procidentia,  where  there  is 
the  greatest  amount  of  continuous  trauma,  cancer  is  extremely  rare.  The 
answer  suggested  to  this  objection  is  that  the  epidermis  in  procidentia  becomes 
so  greatly  thickened  and  hypertrophied  as  to  act  as  an  efficient  protection. 

Theilhaber,  in  his  investigations  in  Munich,  claims  to  have  discovered  a  social  element  in  the 
origin  of  uterine  tumors.  Thus  he  finds  that  cancer  of  the  cervix  is  more  common  among  the 
poor  and  ill-nourished,  while  cancer  of  the  uterine  body  is  more  frequently  found  in  the  well- 
to-do.  When  cervical  cancer  does  appear  in  the  latter  class  it  comes  relatively  later  in  hfe  than 
among  the  poor. 

Uterine  myomata  he  finds  much  more  frequent  among  the  wealthy.  He  explains  this  fact 
as  follows:  "The  frequency  of  uterine  cancer  in  the  poorer  classes  is  not  dependent  on  the 
greater  number  of  confinements  in  this  section  of  population,  but  upon  the  fact  that  the  better 
situated  women  menstruate  on  an  average  five  years  longer  than  the  poorer  women.  In  the 
congested  uterus,  myomata  develop  more  frequently,  whereas  cancers  develop  in  the  poorly 
nourished  organ." 

Symptoms. — Cancer  of  the  cervix  is  very  treacherous,  in  that  it  does  not 
cause  definite  symptoms  in  the  early  stages,  and  because  the  first  symptoms, 
when  they  do  occur,  are  not  apt  to  rouse  the  suspicions  of  the  patient  or  of  her 
physician.  The  three  cardinal  symptoms  of  cancer  of  the  cervix  are  leukorrhea, 
bleeding,  and  pain,  occurring  in  the  order  named.  The  vaginal  discharge  is  due 
at  first  to  an  increase  in  the  normal  secretion  resulting  from  hyperemia,  and  also 
to  a  secretion  from  the  newly  developed  cells.  At  first,  therefore,  the  vaginal 
discharge  of  cancer  differs  from  the  normal  secretion  only  in  quantity  and  not 
in  quality.  Gradually,  however,  when  the  walls  of  the  blood-vessels,  changed 
by  the  tumor  growth,  become  more  permeable,  the  secretion  becomes  mixed  with 
blood  plasm,  and  hence  assumes  a  much  more  watery  character.  This  watery 
consistency  of  the  vaginal  discharge  is  quite  characteristic  of  cancer  of  the 
cervix,  and  is  one  of  the  clinical  signs  that  should  arouse  suspicion  and  urge 
immediate  examination  of  the  patient.  Later,  when  necrosis  of  the  tumor  mass 
takes  place,  with  a  destruction  of  the  superficial  cells  and  consequent  infection 
by  various  organisms  of  decomposition,  the  discharge  becomes  exceedingly  foul 
and  of  a  characteristic  nauseating  odor. 

Bleeding  is  due  partly  to  an  erosion  of  the  capillary  blood-vessels  by  the 
action  of  the  tumor  cells,  and  partly  to  trauma,  by  which  the  delicate  papillary 
outgrowths  are  broken  off  during  movements  of  the  body,  cohabitation,  or  digital 
examination.  Thus,  it  will  be  seen  that  the  cauliflower  type  of  cancer  growing 
from  the  vaginal  portion  of  the  cervix  would  bleed  more  readily  than  the  infil- 
trating form  developing  from  the  endocervix,  in  which  trauma  would  play  a  less 
important  part.     The  cauliflower  type  is  less  treacherous  than  the  other,  as  it 


NEW    GROWTHS  343 

gives  earlier  warning  of  its  presence  by  bleeding.  Bleeding  from  cancer  of  the 
cervix  is  nearly  always  venous.     Fatal  hemorrhages  are,  therefore,  rare. 

The  read}-  bleeding  of  cancer  of  the  cer\'ix  from  coitus  or  digital  examination 
is  a  most  important  sign,  and  does  not  often  exist  to  the  same  degree  in  any  other 
condition. 

The  third  cardinal  symptom,  pain,  is  one  that  is  of  little  value  in  making 
an  early  diagnosis,  as  it  does  not  appear  usually  until  the  case  has  reached  an 
inoperable  stage.  This  is  due  to  the  fact  that  the  cervix  is  a  peculiarly  insensi- 
tive organ,  so  that  while  the  disease  is  confined  to  the  cervix  itself  the  patient 
experiences  no  pain  whatever.  When,  however,  the  cancerous  process  has 
invaded  the  parametrium,  or  has  metastasized  to  the  regional  lymph-glands, 
pain  ensues,  and  as  the  disease  advances  it  may  become  most  excruciating. 
Unilateral  pain  in  the  lower  back,  near  the  ischiadic  region,  is  quite  characteristic, 
and  it  is  often  seen  in  recurrent  cases  following  operation  before  the  recurrence 
can  be  discovered  bj^  objective  signs.  Although  the  presence  of  pain  usually 
signifies  an  inoperable  case,  there  are  exceptions  to  the  rule. 

A  cancer  situated  on  the  anterior  lip  of  the  cervix  tends  to  grow  toward  the 
vagina  and  to  invade  by  extension  the  bladder  wall,  giving  symptoms  of  cystitis. 
In  many  cases  this  is  a  late  symptom,  but  the  invasion  may  occur  while  the  case 
is  still  operable.  It  is  a  serious  comphcation,  however,  and  in  general  makes  the 
prognosis  as  to  recurrence  particularly  bad.  The  invasion  of  the  bladder  often 
causes  a  fistulous  opening  in  the  later  stages.  Implication  of  the  ureters  by 
extension  into  the  parametrium  may  cause  symptoms  of  hydro-ureter  and  hydro- 
nephrosis, due  to  mechanical  obstruction  of  the  ureters.  Wertheim  has  shown 
that  the  ureteral  wall  is  peculiarly  resistant  to  the  invasion  of  cancerous  disease, 
so  that  the  symptoms  are  due  to  external  pressure  from  the  surrounding  new 
growth  masses.  Implication  of  the  rectum  is  rare  and  occurs  only  in  the  most 
advanced  stages. 

It  sometimes  happens  that  infection  from  the  cancerous  growth  extends  to 
the  parametrium  and  pelvic  peritoneum.  This  is  especially  true  of  the  infil- 
trating endocervical  cancer  that  forms  in  the  posterior  lip  and  eats  its  way  into 
the  stroma  of  the  cervix  toward  the  posterior  culdesac. 

In  very  advanced  stages  the  external  genitals  may  become  greatly  swollen 
on  account  of  thrombosis  of  the  pelvic  veins.  General  metastases  to  distant 
parts  of  the  body  are  surprisinglj^  rare,  and  often  do  not  occur  even  in  the  last 
stages. 

The  general  constitutional  symptoms  of  advanced  cancer  of  the  cervix  are 
especially  marked  by  continued  fever  and  by  extreme  cachexia. 

The  elevation  of  temperature  is  variously  explained.  It  is  probable  that 
the  differences  in  the  type  of  fever  which  various  cases  show  bespeak  differences 
in  the  cause.  High,  continuous,  and  remitting  fever,  characteristic  of  sepsis 
and  pyemia,  is  to  be  referred  to  the  activity  of  the  bacteria,  which,  it  is  well 
known,  infect  the  cancerous  mass.     Sapremic  fever  with  a  lower  pulse-rate  than 


344  GYNECOLOGY 

that  of  the  septic  type  is  due  to  the  absorption  of  decomposing  cancer  tissue, 
while  irregular  elevations  of  temperature  are  caused  by  the  destruction  and 
absorption  of  protein  material,  as  in  necrotic  fibroids  and  disintegrating  hema- 
toceles (Koblanck) .  Patients  with  advanced  cancer  of  the  cervix  show  marked 
improvement  after  palhative  operations  of  cureting  and  cauterizing  the  ex- 
crescent masses,  the  improvement  being  largely  due  to  a  diminution  in  the 
amount  of  toxic  absorption.  Temperature  elevation  does  not  ordinarily  appear 
in  the  primary  stages,  so  that  it  is  of  no  great  value  in  making  an  early  "diagnosis. 

The  cachexia  that  results  from  cancer  of  the  cervix  is  extreme,  being  rarely 
equalled  in  any  other  form  of  cancer  in  the  body,  and  is  a  fit  setting  for  this 
gruesome  disease.  It  is  accompanied  with  great  emaciation,  but  neither  cachexia 
nor  loss  of  weight  is  apparent  during  the  early  stages.  The  causes  which  con- 
tribute to  this  cachexia  are  lessened  nutrition  from  loss  of  appetite  and  hemo- 
lytic changes  in  the  blood,  due  to  absorption  of  toxic  products  from  bacterial 
processes  or  from  protein  destruction. 

Prognosis. — The  duration  of  the  disease  from  the  time  of  the  first  appear- 
ance of  symptoms  varies  from  one  to  three  years.  Much  depends  on  the  care 
which  the  patient  receives.  With  occasional  palliative  operations  to  remove 
the  sloughing  masses  and  with  constant  cleansing  of  the  discharges  life  may  be 
prolonged  for  a  surprising  period  of  time  with  comparative  comfort.  Most  of 
these  patients  die  from  wasting  and  exhaustion,  distant  metastases  and  inter- 
current diseases  not  being  common  in  patients  under  careful  treatment.  The  last 
days  of  neglected  cases  are  shorter  than  those  of  patients  under  systematic  care. 

Although  cancer  of  the  cervix  is  one  of  the  most  murderous  of  malignant 
diseases,  the  prospects  of  surgical  cure  are  exceptionally  good  if  an  early  diag- 
nosis can  be  made,  on  account  of  the  slight  tendency  to  metastases.  Early 
diagnoses  are  prevented  partly  by  the  treacherous  onset  of  the  disease  and 
partly  by  the  indifference  of  patients  to  warning  symptoms,  and  the  neglect  of 
physicians  to  make  thorough  vaginal  examinations.  In  Germany,  where  sys- 
tematic education  of  the  laity  is  successfully  carried  out,  patients  come  sooner 
for  treatment,  and  hence  the  percentage  of  operable  cases  is  larger  than  it  is  in 
this  country. 

The  diagnosis  of  cancer  of  the  cervix  is  comparatively  easy.  The  large 
cauliflower  masses  of  cancer  of  the  portio  are  very  characteristic,  and  can  be 
confounded  with  nothing  except  a  sloughing  myomatous  or  mucous  polyp.  In 
the  latter  case  the  pedicle  can  be  made  out  either  by  palpation  or  inspection. 

In  the  ulcerative  form  the  diagnosis  is  somewhat  more  difficult.  There  is 
usually  a  suspicious  hardness  and  irregularity  of  the  cervix  that  calls  attention 
to  the  condition.  Friability  of  the  tissue  with  bleeding  is  the  most  important 
sign,  and  one  that  is  practically  always  present.  Tubercular  and  sj^philitic 
ulcers  are  very  uncommon,  but  may  simulate  cancer,  the  diagnosis  being  readily 
made  by  the  microscope.  Decubitus  ulcers  made  by  ill-fitting  pessaries,  or 
such  as  are  seen  in  procidentia  cases,   are  often  mistaken  for  cancer.     The 


NEW   GROWTHS  345 

ulceration  caused  by  pessaries  heals  up  in  a  short  time  under  treatment,  and  can 
thus  be  distinguished  from  cancer.  In  procidentia  the  decubitus  ulcers  have  a 
characteristic  flat,  dry  appearance,  with  little  tendency  to  bleed,  and  with  a  ^ 
sharply  defined  margin  of  scar  tissue.  One  must  remember,  too,  that  in  proci- 
dentia cancer  of  the  cervix  is  extraordinarily  rare.  Nevertheless,  a  microscopic 
examination  should  be  made  on  the  least  suspicion. 

Ordinary  erosions  of  the  cervix  often  simulate  cancer  closely.  The  general 
cei-vicitis,  with  Nabothian  cyst  formation  that  is  frequently  associated  vvdth 
erosion,  may  be  very  suggestive  of  an  infiltrating  cancer  of  the  cervix,  while  it 
occasionally  happens  that  an  erosion  may  bleed  on  digital  examination  or  after 
coitus  as  freely  as  would  an  early  cancerous  growth.  The  finding  of  Nabothian 
cysts  in  cervicitis  cases  is  usually  evidence  that  the  condition  is  not  cancer. 
According  to  Schroder,  the  presence  of  these  cysts  absolutely  rules  out  cancer. 
This,  however,  is  an  error,  for  we  have  found  instances  in  which  an  early  cancer 
existed  side  by  side  with  extensive  Nabothian  cysts  and  general  cervicitis. 
Frommel  has  reported  two  such  cases  and  Koblanck  has  reported  one.  It  is 
probable  that  if  cancers  of  the  cervix  were  oftener  observed  at  an  early  stage  the 
combination  with  cystic  cervicitis  would  be  found  to  be  not  infrequent. 

The  infiltrating  form  of  cancer  starting  from  the  endocervical  portion  may 
often  be  very  difficult  of  diagnosis,  especially  in  cervices  that  have  undergone 
senile  atrophy.  There  may  be  no  apparent  enlargement  of  the  cervix,  and  its 
outward  appearance,  as  observed  through  the  speculum,  may  be  perfectly 
normal.  A  watery  discharge  or  bleeding  are  the  warning  signals:  The  con- 
dition usually  confounded  with  this  type  of  cancer  is  senile  vaginitis,  senile 
cervicitis,  or  pyometra.  In  the  latter  class  of  cases  there  may  be  bleeding  from 
eroded  areas  of  the  vaginal  wall,  and  the  discharge,  especially  if  partially  ob- 
structed by  plastic  adhesions  of  the  cervix  or  vagina,  may  become  excessively 
foul  and  have  an  odor  very  like  that  of  cancer.  The  discharge,  however,  is 
usually  thick  and  creamy,  containing  as  it  does  great  quantities  of  desquamated 
epithelium,  as  distinguished  from  the  thin  watery  discharge  of  cancer.  If 
blood  is  present  a  careful  examination  must  be  made  in  the  Sims  position,  to 
determine  whether  it  comes  from  the  uterus  or  from  a  superficial  erosion  of  the 
vagina.  If  the  blood  is  from  the  uterus,  the  probabilities  are  very  much  in  favor 
of  cancer  and  an  immediate  intra-uterine  examination  is  urgent. 

Every  single  case,  either  of  suspected  or  of  perfect^  obvious  cancer,  should 
have  a  specimen  removed  for  microscopic  examination.  Even  if  the  case  is, 
be3'ond  question,  one  of  cancer  a  microscopic  examination  of  a  section  from  the 
growth  should  be  made  merely  as  a  matter  of  record,  for  no  report  of  a  cancer 
case  is  complete  or  authentic  without  this  evidence. 

From  the  standpoint  of  diagnosis  the  microscope  is  of  supreme  importance. 
The  surgical  errors  of  omission  and  commission  in  cancer  of  the  uterus  are  almost 
invariably  due  to  a  neglect  of  this  routine  principle. 

Unfortunatelj^,  the  removal  of  a  specimen  from  the  cervix  is  a  matter  of  some 


346  GYNECOLOGY 

technical  difficulty,  and  it  is  doubtless  for  that  reason  that  this,  all-important 
step  in  the  diagnosis  is  so  frequently  omitted  by  the  general  practitioner.  The 
procedure  may  be  done  in  the  Sims  position  with  the  aid  of  a  Sims  speculum. 
The  light  must  be  good,  and  at  least  one  assistant  is  needed.  It  is  necessary 
to  use  long  vaginal  scissors  and  forceps  or  some  special  instrument,  of  which 
there  are  several  types  on  the  market.  In  removing  a  specimen  from  an  ulcer- 
ated area  when  the  tissue  is  friable  and  bleeding  this  small  operation  may  be- 
come quite  difficult.  Only  a  small  bit  of  tissue  is  necessary,  and  it  should  be  put 
at  once  into  5  per  cent,  formalin  solution  and  sent  to  a  pathologist  for  frozen 
section  and  examination.  For  the  infiltrating  form  of  cancer  of  the  cervix  a 
specimen  can  best  be  removed  by  a  small  curet.  No  anesthesia  of  any  kind 
is  necessary.  The  bleeding  that  is  caused  is  not  dangerous  and  is  easily  con- 
trolled by  tampons. 

Operability.— When  the  diagnosis  of  cancer  of  the  cervix  is  confirmed,  the 
next  step  is  to  determine  the  operability  of  the  case.  This  depends  on  the 
amount  of  extension  which  the  disease  has  undergone  beyond  the  uterus.  As 
the  cancerous  process  invades  the  parametrium  or  inffitrates  the  wall  of  the 
vagina,  the  uterus  gradually  becomes  fixed,  so  that  the  extension  of  the  disease 
is  determined  chiefly  by  the  mobiUty  of  the  uterus.  This  sign  is,  however, 
a  deceptive  one,  for  it  may  be  influenced  by  other  factors.  Thus,  a  large  cauli- 
flower mass,  extending  from  the  portio  into  the  vagina,  may  cause  the  impres- 
sion of  general  immobility,  whereas,  after  cureting  the  mass  away,  the  uterus 
may  be  found  to  be  comparatively  free  and  movable,  with  little  extension  of  the 
disease  into  the  parametrium.  Not  infrequently  the  parametrial  infiltration 
is  entirely  inflammatory  in  character.  It  is  impossible  to  distinguish  this  con- 
dition from  cancer  by  digital  examination,  and  it  is  not  always  possible  to  tell 
the  difference  even  after  the  abdomen  is  opened.  It  should  be  noted,  therefore, 
that  many  cases  are  entirely  operable  v/hicli  on  first  examination  seemed  hope- 
less. It  is  also  important  to  remember  that  the  operabihty  oftentimes  can  be 
determined  only  by  an  exploratory  laparotomy,  and  there  should  never  be 
any  hesitancy  in  performing  one  if  there  is  the  slightest  hope  of  finding  the  case 
operable. 

The  presence  of  cancerous  infection  of  the  regional  lymph-glands  is  regarded 
by  some  as  a  contra-indication  to  radical  operation  on  the  ground  that  recur- 
rence is  sure  to  follow.  The  presence  of  infected  lymph-glands  unquestionably 
makes  the  prognosis  unfavorable,  but  by  no  means  hopeless,  as  Wertheim  and 
others  have  shown  permanent  cures  in  such  cases  after  extirpation  of  the  glands. 
The  presence  of  enlarged  glands  in  a  case  of  cancer  of  the  cervix  does  not  neces- 
sarily mean  that  they  are  cancerous,  for  a  considerable  percentage  of  them  are 
inflammatory  and  show  no  microscopic  evidence  of  cancer.  When  the  disease 
has  metastasized  to  the  regional  lymph-glands  the  case  is  more  favorable  if  only 
a  single  gland  is  infected,  even  though  extensively,  than  when  there  is  multiple 
involvement. 


NEW   GROWTHS  347 

Involvement  of  the  bladder  wall  and  of  the  tissue  surrounding  the  ureters 
does  not  necessarily  eontra-indicate  operation,  for  portions  of  the  bladder  may 
be  resected  successfully'  and  the  ureters  may  be  freed  from  extensive  growths, 
or  resected  and  transplanted  into  the  bladder,  without  later  recurrence  of  the 
disease. 

The  question  of  operability  depends  to  a  considerable  extent  on  the  method 
of  operation  employed.  The  development  of  the  extended  abdominal  opera- 
tion for  cancer  of  the  cervix  has  greatly  increased  the  percentage  of  operable 
cases.  Whereas  formerly  the  number  of  cases  considered  suitable  for  operation 
averaged  about  10  to  15  per  cent,  of  all  those  seen,  now  the  percentage  of  cases 
operated  on  averages  50  per  cent.  Wertheim's  figure  is  61  per  cent.,  while 
Bumm  claims  90  per  cent.  In  this  country,  where  the  laity  and  the  profession 
are  poorly  educated  in  the  subject  of  cancer  of  the  cervix,  there  are  only  a  few 
localities  where  the  operability  percentage  would  be  as  high  as  50  per  cent., 
and  in  most  places  the  proportion  falls  far  below  that. 

Operative  Treatment. — There  are  at  the  present  time  two  principal  methods 
of  operating  on  cancer  of  the  cervix,  namely,  total  extirpation  of  the  uterus, 
either  by  the  vaginal  or  the  abdominal  route.  Schauta  is  the  chief  exponent 
of  the  vaginal  operation,  while  Wertheim  is  the  most  famous  advocate  of  the 
latter  method. 

Abdominal  extirpation  of  the  uterus  for  cancer  of  the  cervix  was  first  per- 
formed by  W.  A.  Freund  in  1878,  who,  after  a  series  of  experiments  on  the 
cadaver,  operated  successfully  on  a  case  and  published  the  technic  of  his  opera- 
tion. Freund's  operation  is  the  one  used  at  the  present  day,  and  to  him  must 
be  given  the  credit  of  originality,  while  to  Wertheim  belongs  the  distinction  of 
popularizing  the  operation  and  making  it  of  great  clinical  value.  The  technic 
of  the  procedure  with  Wertheim's  individual  modifications  is  described  on  page 
731. 

There  seems  to  be  little  doubt  that  the  extended  abdominal  route  for  cancer 
of  the  cervix  is,  in  general,  preferable  to  the  vaginal,  the  chief  advantage  of  the 
operation  being  that  more  room  is  secured  for  wide  dissection  of  the  parametrial 
tissue,  so  that  it  is  possible  b}^  this  method  to  operate  on  much  more  advanced 
■cases  than  is  possible  by  vagina. 

Figures  showing  the  number  of  final  cures  after  the  five-year  limit  are  in 
favor  of  the  abdominal  route,  when  it  is  taken  into  consideration  that  much  more 
♦  advanced  cases  are  operated  on  in  this  way.  The  mortality  percentage  is  some- 
what lower  in  the  statistics  of  the  vaginal  method  than  in  those  of  the  abdominal, 
but  here  again  one  must  take  into  account  that  the  cases  performed  by  the 
latter  method  are,  on  the  average,  considerably  more  serious. 

The  following  figures  represent  the  average  results  from  the  leading  clinics 
in  which  the  abdominal  operation  is  performed: 

Operability:  50  per  cent,  of  all  cases  that  present  themselves  for  treat- 
ment. 


348  GYNECOLOGY 

Primary  Mortality:    11  to  15  per  cent.,  the  most  common  causes  of  death 
being  peritonitis  and  shock  from  hemorrhage. 
Cures:   30  per  cent,  after  the  end  of  five  years. 

Other  Methods  of  Treating  Cancer  of  the  Cervix 

Radiation  Treatment  of  Cancer.— In  the  present  status  of  our  knowledge  and 
experience  in  the  use  of  radiation  for  the  treatment  of  malignant  disease  no 
didactic  statements  should  be  made.  We  can  only  summarize  what  has  been 
accompHshed  to  date,  and  speculate  from  these  data  as  to  possibilities  of  future 
success  in  this  promising  field  of  therapy. 

It  may  be  said  in  general  that  as  a  palhative  agent  for  certain  forms  of  cancer 
radiation  has  proved  itself,  beyond  all  question,  to  be  of  inestimable  value;  as  a 
measure  for  the  complete  and  permanent  cure  of  cancer  no  definite  conclusions 
can  as  yet  be  drawn,  but  there  is  much  evidence  to  show  that  with  a  greater 
knowledge  of  the  subject  and  improved  methods  of  application  the  treatment 
will  prove  to  be  curative  in  many  forms  of  mahgnant  disease. 

Up  to  the  present  time  radiation  has  had  its  best  success  in  various  forms  of 
epitheliomata,  on  account,  no  doubt,  of  the  easier  access  to  this  type  of  cancer, 
most  brilhant  results  having  been  attained  in  the  treatment  of  epitheliomata  of 
the  uterine  cervix.  For  this  reason  the  subject  is  one  of  especial  interest  to  the 
gynecologist. 

Radiation  in  the  treatment  of  cancer  is  at  present  being  given  by  the  x-ray, 
in  the  form  of  mesothorium,  in  the  form  of  radium,  or  in  the  form  of  emana- 
tions. As  a  rule,  the  Rontgen  rays  are  used  only  as  an  aid  to  radium  or  meso- 
thorium, for,  though  they  exercise  the  same  biologic  effect  on  the  tissue  as  the 
two  radio-active  substances,  their  penetrability  is  much  less. 

The  radio-active  substances,  radium  and  mesothorium,  according  to  present 
theories,  exercise  their  influence  on  the  tissues  by  means  of  three  kinds  of  rays, 
termed  alpha,  beta,  and  gamma  rays,  which  differ  from  each  other  in  velocity, 
penetrability,  effect  on  the  tissues,  etc.  Of  these  three,  the  gamma  rays  and  the 
hard  beta  rays  are  of  pre-eminent  use  in  the  treatment  of  cancer,  for,  in  addition 
to  their  greater  penetrating  power,  they  have  a  selective  action  in  destroying  the 
cancer  cells  without  injuring  the  cells  of  the  surrounding  normal  tissues. 

Burnam  describes  the  physical  properties  of  radium  thus: 

"Radium  is  a  metallic  element  belonging  to  the  strontium  barium  group.  It  readily  forms 
salts  with  the  mineral  acids  and  is  the  leading  member  of  the  peculiar  radio-active  group  of 
elements  which  are  characterized  by  atomic  instability.  Radium  itself  is  formed  by  atomic 
reduction  from  uranium.  It  loses  a  portion  of  its  atom  to  become  a  gas  called  radium  emana- 
tion, and  this,  in  turn,  is  the  mother,  grandmother,  etc.,  of  a  series  of  solid  elements.  The  so- 
called  radium  C,  third  in  series  from  the  emanation,  is  that  member  of  the  group  which  par- 
ticularly concerns  us,  as  it  is  from  it  that  both  the  beta  and  gamma  rays  are  derived.  Radium 
emanation  can  be  separated  from  radium  as  fast  as  it  is  formed.  A  given  amount  of  radium  is 
capable  of  producing  a  given  amount  of  emanation.  The  emanation  reaches  a  maximum  and 
then  disintegrates  at  the  same  rate  that  it  is  being  formed.     In  about  four  days  a  given  amount 


NEW    GROWTHS  349 

is  reduced  to  one-half.  If  radium  or  radium  emanation  is  sealed  in  a  glass  or  a  metal  container 
it  begins  to  produce  radium  C.  The  maximum  amount  of  radiimi  C  is  obtained  in  a  radium 
preparation  so  placed  in  a  glass  tube  in  thirty  days.  The  maximum  amount  from  emanation  is 
produced  in  three  hours  and  thirty  minutes.  Radium  C  itself  can  be  isolated,  but  has  such  a 
short  Ufe,  only  two  or  three  hours  total,  that  it  cannot  be  effectually  used  in  practical  treatment. 

"The  essential  characteristic  of  the  radio-active  substances  is  the.  giving  off  of  invisible  rays. 
These  rays  must  not  be  confused  with  the  emanation,  which  is  an  element  just  as  radium  itself  is. 
The  rays  have  been  divided  according  to  their  physical  characteristics  into  three  kinds :  the  al- 
pha, the  beta,  and  the  gamma. 

"The  alpha  ray  is  a  positively  charged  atom  of  helium.  It  has  a  very  small  power  of  pene- 
tration, being  completely  stopped  by  a  thin  sheet  of  writing  paper.  It  acts  very  powerfully 
toward  inducing  chemical  change  in  both  inorganic  and  organic  matter  brought  in  contact  with 
it.  The  beta  ray  is  a  negatively  charged  electric  ion  which  has  about  the  velocity  of  light  and 
will  easily  penetrate  several  centimeters  of  living  tissue.  It  has  also  a  marked  capacity  for 
inducing  chemical  changes  in  organic  matter  subjected  to  it.  The  gamma  ray  is  not  particulate 
matter,  but  a  vibration  of  ether  similar  to  ordinary  light  and  of  the  .r-ray.  It  differs  from  them 
in  being  of  much  shorter  wave  length  and  of  much  greater  penetration.  It  has  power  also, 
but  to  a  lesser  degree  than  the  alpha  and  beta  rays,  to  produce  chemical  change  in  organic  mat- 
ter exposed  to'  it.  When  a  radium  salt  is  enclosed  in  a  glass  tube,  alpha,  beta,  and  gamma  rays 
are  produced  within  the  container.  The  alpha  rays  are  held  in  the  tube,  while  the  beta  and 
gamma  rays  penetrate  its  walls,  and  pass  out  into  the  surrounding  medium  in  radial  lines,  thus 
making  a  sphere  of  radiation.  When  the  glass  tube  is  further  surrounded  by  2  mm.  of  lead,  the 
hardest  beta  rays  can  no  longer  penetrate  this  envelope.  It  is  possible,  therefore,  in  medical 
treatments  to  use  all  three  kinds  of  rays  together,  the  beta  and  gamma  rays  together,  or  the 
gamma  rays  alone.  It  is  impossible  to  use  the  alpha  rays  alone,  and  it  is  difficult  to  use  the 
beta  rays  alone  in  anything  except  experimental  work. 

"From  the  above  it  is  evident  that  radium  or  one  of  its  derivatives  can  be  used  in  two  essen- 
tially different  ways:  first,  it  can  be  taken  into  the  body  by  mouth,  hypodermically  or  intra- 
venously as  any  other  soluble  drug ;  second,  it  can  be  applied  from  either  outside  or  inside  the 
body  in  sealed  tubes  or  other  containers  in  the  same  general  way  that  an  x-ray  tube  is  employed." 

In  order  to  avoid  burning  or  the  unfavorable  stimulating  action  of  the  soft 
alpha  and  beta  rays  on  the  cancer  tissues  a  filter  must  be  used.  This  is  at 
present  accomplished  only  incompletely  by  encapsulating  the  radial  substance 
in  some  form  of  metal.  Of  the  metal  filters  used  may  be  mentioned  lead,  silver, 
brass,  gold,  platinum,  and  aluminum.  There  is  no  unanimity  of  opinion  as  to 
the  best  form  of  filter,  the  problem  evidently  not  yet  having  been  solved,  though 
there  is  some  evidence  that  brass  causes  the  lowest  percentage  of  loss  of  the 
gamma  rays  (Henkel). 

There  is  also  difference  of  opinion  regarding  the  amount  of  radio-active  sub- 
stance to  use  in  a  given  case,  and  also  the  length  of  time  for  its  application. 
Most  experimenters  are  using  from  50  to  100  mg.  of  radium  or  mesothorium  for 
cancer  of  the  cervix,  the  time  of  exposure  varying  from  three  or  four  hours  to 
five  days  and  more.  An  interval  of  from  ten  days  to  three  weeks  is  given  be- 
tween the  treatments  or  series  of  treatments.  Although  the  gamma  rays  are 
capable  of  penetrating  several  inches  of  battleship  steel,  it  has  been  shown 
experimentally  that  the  power  of  destroying  cancer  cells  extends  only  about  3  to 
4  cm.  below  the  surface.  Beyond  this  so-called  killing  point  the  gamma  rays 
have  an  inhibitory  action  on  the  growth  of  the  cancer  cells. 

Destruction  of  the  cells  acted  on  by  the  gamma  rays  is  shown  by  sweUing 


350  GYNECOLOGY 

and  vacuolization  of  the  protoplasm  and  shrinking  of  the  nuclei,  followed  by- 
phagocytosis  and  absorption.  The  space  occupied  by  the  destroyed  cells  is 
replaced  by  a  homogeneous  connective-tissue  mesh  work. 

Local  changes  of  a  gross  nature  depend  to  a  considerable  extent  on  the  char- 
acter of  the  growth.  In  advanced  cases,  especially  if  the  cancer  is  of  the  inverting 
type,  the  effects  of  radium  may  be  comparatively  slight.  It  is  our  opinion  that 
the  histologic  structure  of  the  disease  has  an  important  bearing  on  its  reaction 
to  radium  influence,  for  it  has  been  our  observation  that  the  cervical  cancers  of 
the  adenomatous  type  are  less  susceptible  to  successful  treatment  than  are  those 
of  the  squamous-cell  variety.  This  is  quite  true  of  cancers  in  other  parts  of 
the  body  and  may  be  due  to  some  inherent  reactive  property  in  the  cancer  cell 
itself  or  to  the  fact  that  epitheliomatous  cancers  are  usually  more  accessible  for 
the  direct  application  of  radium.  In  cervical  cancer  the  glandular  types  orig- 
inate from  the  endocervical  epithelium  and  have  a  special  tendency  to  extend 
inward  toward  the  parametrium.  It  is  more  difficult,  therefore,  to  reach  them  with 
radiation.  The  purely  squamous  epitheliomata  originate  from  epithelium  of  the 
vaginal  portion  of  the  cervix  and  tend  to  grow  outward  into  the  vagina.  In 
cancers  of  this  kind  radium  produces  astonishing  results.  Even  large  cauliflower 
growths  filling  the  vagina  may,  in  three  or  four  weeks,  with  no  other  treatment 
than  a  few  applications  of  radium,  be  made  to  vanish  without  bleeding  or  dis- 
charge. 

The  condition  of  the  cervix  and  vaginal  vault  after  a  successful  course  of 
radium  treatment  is  characteristic.  In  place  of  the  cancer  mass  there  is  left  a 
thick  yellowish  membrane  densely  adherent  which  may  persist  for  several 
months.  The  cervix  and  vaginal  vault  undergo  a  peculiar  shrinkage  which 
simulates  somewhat  the  changes  of  senile  atrophy.  The  vagina,  which  normally 
is  broad  and  roomy  at  the  vault,  narrows  down  into  the  form  of  a  cone.  At  the 
apex  is  the  cervix,  which  has  completely  lost  its  conformation  and  exists  now  only 
as  a  dimple.  Investing  the  upper  vagina  is  seen  the  yellow  adherent  exudate 
mentioned  above.  To  the  examining  finger  the  tissues  present  an  entirely 
characteristic  feeling  of  fibrous  density.  The  parametria  are  often  rigid,  while 
definite  thickenings  are  sometimes  felt  in  the  paravaginal  tissue,  especially  in 
the  rectovaginal  septum.  In  cases  in  which  the  paravaginal  reaction  is  severe 
there  are  usually  symptoms  of  vesical  or  rectal  tenesmus  according  to  the  organ 
toward  which  the  infiltrating  process  extends.  The  mucous  membrane  of  the 
bladder  or  rectum  may  be  affected,  with  resulting  cystitis  or  mucous  colitis. 

Involvement  of  the  paravaginal  tissue  affecting  the  adjacent  organs  is  usually 
the  outcome  of  insufficient  screening  and  not  infrequently  results  in  fistulse 
which  may  not  appear  until  long  after  the  application  of  the  radium.  An  opera- 
tion performed  during  the  stage  of  infiltration  encounters  great  technical  difficul- 
ties. The  cellular  tissue  is  vague  and  confused  and  the  normal  planes  of  cleavage 
are  obliterated.     The  bleeding  is  free  and  difficult  to  control. 

It  seems  probable  that  the  thickening  of  the  parametrial  and  paravaginal 


NEW    GROWTHS  351 

cellular  tissue  represents  a  form  of  inflammatory  reaction,  for  in  the  course  of 
three  or  four  weeks  it  gradually  diminishes  and  the  tissues  assume  a  somewhat 
more  pliable  consistency.  It  is  noteworthy  that  if  there  exists  a  pelvic  inflam- 
matory process  at  the  time  of  the  radium  application,  the  condition  may  be 
Hghted  up  into  an  acute  stage;  while  a  radical  operation  performed  during  the 
reaction  stage  is  very  apt  to  be  followed  by  serious  sepsis.  These  two  facts  seem 
to  support  the  theory  that  the  reaction  is  of  an  inflammatory  nature. 

In  the  course  of  six  or  seven  weeks  the  parametria  again  become  tight  and 
rigid.  This  is  due  to  a  scar-Hke  shrinkage,  an  unyielding  sclerosis,  of  the  cellular 
tissue.  If  an  operation  is  undertaken  at  this  time  serious  difficulties  are  also  met 
with.  The  planes  of  cleavage  are  permanently  obliterated,  so  that  the  separation 
of  bladder  from  cervix  and  vagina  and  the  isolation  of  the  m'eters  can  be  done  only 
by  dangerous,  painstaking  dissection. 

According  to  Frank,  the  shrinkage  process  of  the  parametrial  cellular  tissue 
plays  a  part  in  the  temporary  curative  effect  produced  by  radimn.  From  his 
histologic  studies  he  finds  that  after  a  maximum  exposure  the  radium  manifests 
a  direct  action  on  the  cancer  cells  for  only  a  distance  of  1.5  cm.,  but  that  the 
curative  effect  may  be  seen  throughout  a  much  wider  area.  In  order  to  account 
for  this  he  believes  that  some  other  local  factor  must  come  into  play.  To  quote 
Frank:  'This  local  factor,  in  the  case  of  cervical  carcinoma,  is  probably  suppHed 
by  the  large  quantity  of  connective  tissue  (parametria)  which  radiates  from  the 
cervix  in  all  directions.  Under  the  influence  of  the  rays  the  connective  tissue 
contracts,  hardens,  and  perhaps  proliferates.  As  a  result,  the  lymphatics  and 
smaller  blood-vessels  are  permanently  blocked,  and  the  dense  scar  produces  a 
condition  of  "starvation"  of  the  growth,  a  condition  which  has,  at  times,  been  ob- 
tained by  surgical  means  (ligation  of  the  internal  iliac  arteries). 

The  selective  action  of  the  ganama  rays  on  cancerous  tissue  is  most  marked 
if  the  radium  is  placed  either  in  contact  with  or  within  the  tumor  mass.  If 
normal  tissues  intervene  the  dosage  must  be  much  greater  and  the  effect  is  less 
favorable. 

Harm  may  be  done  either  by  an  overdosage  or  an  underdosage.  If  the  dose 
of  radium  is  too  powerful,  there  may  result  an  excessive  destruction  and  absorp- 
tion of  the  tissues.  If  the  dose  is  insufficient,  it  may  result  in  stimulating  the 
growth  to  fresh  activity. 

Harris  summarizes  the  therapeutic  value  of  radium  by  stating  that  its 
efficacy  depends:  (1)  Upon  the  amount  used;  (2)  the  amount  and  nature  of 
filtration;  (3)  the  distance  from  the  tumor  tissue;  (4)  the  length  of  exposure; 
(5)  the  resistance  of  the  tissue,  and  (6)  the  number  and  length  of  exposures,  as 
determined  by  the  cHnical  judgment  of  the  user. 

In  a  favorable  case  the  local  effect  of  radium  on  cancer  of  the  cervix  is  very 
remarkable.  The  fetid  discharge  and  odor  ceases,  bleeding  stops,  and  the 
tumor  masses  and  nodules  rapidly  melt  away  and  disappear.  In  some  cases, 
which  before  treatment  seemed  hopelessly  inoperable,  no  sign  of  cancer  can  be 


352  GYNECOLOGY 


detected  by  bimanual  examination.     Pain  is  often  relieved  immediately  and 
completely. 

Favorable  results  of  radium  treatment  are  also  seen  in  the  early  treatment 


Fig.  110. — Section  of  Cervical  Cancer  Removed  by  a  Wertheim  Operation  After  Treat- 
ment WITH  Radium. 
Radium  had  evidently  been  inserted  in  the  cer\-ical  canal.  The  cancer  cells  near  the  cervical 
canal  and  in  the  interior  of  the  cancer  mass  have  been  destroyed.  The  darker  portions  around  the 
periphery  of  the  mass  show  the  presence  of  active  cancer  cells.  This  is  a  drawing  from  a  section 
made  at  Wertheim's  clinic,  and  lent,  to  the  author  by  Dr.  T.  A.  Ordway. 

of  recurrences  following  radical  operation,  especially  when  the  recurrence  takes 
place  in  the  scar  at  the  vault  of  the  vagina. 

Unfortunately,  all  cancer  cases  of  the  cervix  do  not  react  in  the  satisfactory 


NEW    GROWTHS  353 

manner  that  we  have  described  above.  In  certain  far-advanced  stages  radium 
may  stimulate  the  growth  to  renewed  activity  of  a  most  alarming  nature, 
death  being  hastened  by  many  months.  This  is  in  line  with  the  observation  of 
Seuffert  that  the  younger  the  cell,  whether  cancerous  or  normal,  the  more 
sensitive  it  is  to  the  action  of  radium.  In  the  presence  of  pelvic  infection,  such 
as  may  exist  from  extension  from  the  cancer  through  the  parametrium,  or  such 
as  may  result  from  a  previous  tubal  inflammation,  the  application  of  radium  is 
apt  to  set  up  an  active  pelvic  peritonitis. 

If  the  cancer  has  involved  the  bladder  or  rectal  wall,  radium  treatment  is 
apt  to  result  in  large  fistulas,  a  possibility  which  in  the  advanced  cases  often 
contra-indicates  the  treatment. 

It  has  been  the  author's  experience  that  there  is  greatly  increased  danger  of 
postoperative  sepsis  if  a  radical  operation  is  performed  too  soon  after  a  radium 
treatment.  This  was  shown  in  three  successive  cases  in  which  the  operation 
was  performed  within  a  few  days  of  the  last  treatment.  Other  operators,  not- 
ably Wertheim,  have  made  the  same  observation.  The  cause  of  this  is  a  matter 
of  speculation.  It  would  seem  either  that  the  sepsis  is  the  result  of  the  presence 
in  the  tissues  of  latent  organisms  that  are  stirred  up  to  new  activity  by  the 
influence  of  the  rays,  or  that  the  rays  devitalize  the  normal  tissues  and  produce 
in  them  a  temporary  lack  of  resistance  to  infective  organisms. 

In  most  cases  there  is  very  little  systemic  reaction  after  the  use  of  radium, 
but  some  patients  complain  of  headache,  loss  of  appetite,  pain  in  the  intestines 
and  bladder,  constipation,  and  diarrhea.  There  is  sometimes  a  rise  of  tempera- 
ture, probably  due  to  the  stirring  up  of  some  local  inflammatory  process  or  the 
absorption  of  the  necrotic  cell  material.  Elderly  people  and  those  in  a  much 
depleted  physical  condition  may  be  made  very  sick.  In  one  of  our  cases  an 
acute  nephritis  with  alarming  symptoms  followed  the  first  radium  treatment, 
though  it  rapidly  subsided. 

It  has  been  said  that  the  reason  that  the  best  results  of  radium  treatment 
have  been  reported  by  gynecologists  is  because  cancer  of  the  cervix  has  com- 
paratively little  tendency  to  metastasize,  and  this  is  undoubtedly  true.  If  the 
cancerous  process  has  extended  to  the  regional  lymph-glands,  radium  treatment 
is  of  comparatively  little  value,  excepting  for  its  effect  on  the  primary  focus. 
Veit,  however,  is  of  the  opinion  that  irradiation  of  the  primary  cervical  focus 
may  cause  a  regression  of  the  disease  in  the  lymph-glands.  Scheuer  thinks  that 
the  Rontgen  rays  have  a  power  of  reaching  gland  metastases  and  parametrial 
infiltration  better  than  do  the  rays  of  mesothorium  and  radium. 

Selection  of  Cases  for  Radium  Treatment. — In  the  treatment  of  a  given  case 
of  cervical  cancer  numerous  factors  requiring  experience  and  careful  judgment 
must  be  taken  into  account.  Most  important  of  all  is  the  question  between  rad- 
ical operation  and  the  employment  of  radium.  If  the  case  is  manifestly  operable 
the  preliminary  use  of  radium  should  be  excluded  at  once.    In  such  a»case  radium 

23 


354  GYNECOLOGY 

will  usually  cause  the  cancerous  growth  to  disappear  as  if  by  magic,  and  one  is 
tempted  to  resort  to  this  easy  and  painless  method  of  treatment  in  place  of  the 
difficult  and  somewhat  dangerous  radical  operation.  There  is,  however,  no  present 
undisputed  evidence  that  even  a  favorable  case  of  cervical  cancer  may  be  per- 
manently cured  by  radium,  whereas  skilful  operation  cures  many  such  cases 
with  comparatively  small  primary  mortality.  Moreover,  it  must  not  be  supposed 
that  in  an  operable  case  a  preliminary  treatment  with  radium  will  render  a  later 
radical  operation  less  difficult.  We  have  described  above  the  pecuUar  effect 
which  radium  produces  in  the  parametria,  and  it  may  be  said  with  emphasis 
that  in  no  case  that  is  primarily  operable  can  a  radical  extirpation  of  the  uterus 
be  as  easily  and  extensively  performed  after  radium  treatment  as  it  could  have 
been  without  such  treatment. 

This  statement,  however,  does  not  preclude  the  preliminary  use  of  radium 
as  a  preparation  for  operation  under  certain  conditions.  On  the  contrary, 
many  inoperable  cases  of  cervical  cancer  may  be  made  operable  by  radium,  and 
it  is  in  this  particular  field  that  the  treatment  possesses  one  of  its  greatest  values. 
In  this  category  are  included  those  doubtful  cases  the  operability  of  which  de- 
pends on  the  expertness  of  the  operator  and  his  courage  in  undertaking  desper- 
ate surgery.  They  are  the  cases  that  entail  a  high  percentage  of  primary  mor- 
taHty,  or  if  the  operation  is  not  fatal,  a  high  i^ate  of  recurrence  of  the  disease. 
Occasionally  cases  which  not  even  the  most  optimistic  surgeon  would  venture  to 
operate  upon  may  be  made  operable  by  a  course  of  radium  treatment.  The 
possibility  of  making  an  inoperable  case  operable  requires  that  the  patient  should 
be  kept  under  frequent  observation,  so  that  the  most  favorable  time  for  surgical 
interference  may  be  chosen.  As  stated  above,  this  is  usually  about  three  weeks 
after  a  radium  treatment.  In  operating  on  a  case  of  this  kind  we  have  found  it 
advisable  not  to  attempt  too  extensive  a  dissection  of  the  parametrial  and  para- 
vaginal tissues,  and  we  are  usually  content  to  perform  a  complete  hysterectomy 
with  as  wide  a  removal  of  the  vaginal  wall  as  possible.  In  this  way  many  patients 
may  be  given  a  year  or  two  of  health  and  comfort  and  occasionally  probably 
cured  permanently. 

A  third  class  of  patients  with  cervical  cancer  consists  of  those  in  whom  the 
disease  is  hopelessly  advanced  as  far  as  any  chance  of  cure  is  concerned.  In 
these  cases  radium  is  one  of  the  most  valuable  resources  for  palliative  treatment. 
Bleeding  and  foul  discharge  may,  as  a  rule,  be  temporarily  stopped  and  pain  is 
sometimes  completely  controlled  or  at  least  palliated.  It  is  feasible  to  treat 
with  radium  nearly  all  cases  of  advanced  cervical  cancer  except  those  with 
rectal  or  vesical  fistula. 

A  fourth  class  of  patients  is  represented  by  those  who  present  local  recurrence 
in  the  vault  or  lateral  walls  of  the  vagina  after  radical  operation.  In  all  of 
these  cases  radium  treatment  is  strongly  indicated  unless  there  exist  fistulse 
into  bladder  or  rectum.     Early  recurrences  may  often  be  controlled  for  long 


NEW    GROWTHS  355 

periods  of  time  when  treated  judiciously  with  radium.  For  this  reason  patients 
who  have  undergone  operation  should  be  examined  frequently  in  order  that  the 
earliest  indication  of  recurrence  may  be  noted. 

Still  a  fifth  class  of  patients  concerning  whom  the  question  of  radium  treat- 
ment presents  itself  comprises  those  in  whom  a  successful  radical  operation 
has  been  performed.  In  these  cases  many  advocate  a  periodic  application  of 
radium  to  the  vaginal  vault  as  a  prophylactic  against  recurrence.  How  much 
good  this  accomplishes  is  problematic,  but  if  radium  is  employed  conservatively 
no  harm  is  done  and  both  surgeon  and  patient  have  the  satisfaction  of  feeling 
that  in  the  light  of  present  knowledge  every  available  resource  has  been  used 
to  effect  a  permanent  cure. 

A  sixth  class  of  patients  who  present  themselves  for  radium  treatment  con- 
sists of  those  who  exhibit  postoperative  metastatic  recurrences  in  the  regional 
lymph-glands.  These  patients  suffer  excruciating  pain  which  can  only  be  allevi- 
ated by  large  doses  of  morphin.  In  cases  of  this  kind  it  has  been  our  experi- 
ence that  local  applications  of  radium  in  the  vaginal  vault  give  little  more  than 
imaginary  relief.  Dr.  Kelly  reports  favorable  results  from  applying  an  enormous 
quantity  of  radium  for  short  periods  of  time  externally  at  the  point  most  closely 
related  to  the  seat  of  pain.  Ordinary  amounts  of  radium  used  in  this  way  have 
little  or  no  effect. 

A  final  type  of  case  which  comes  under  consideration  includes  those  patients 
in  whom  fistulas  between  bladder  or  rectum,  or  both,  have  been  established, 
or  in  whom  ulceration  of  the  cancerous  growth  has  progressed  so  far  that  fistula 
formation  is  imminent.  In  cases  of  well-established  fistula  we  can  see  no  advan- 
tage in  the  use  of  radium,  for  if  the  fistula  has  been  created  by  the  disease,  radium 
will  only  increase  the  size  of  the  fistula  and  at  this  stage  will  be  of  little  effect 
in  checking  the  progress  of  the  cancer.  If  the  fistula  is  the  result  of  a  previous 
radium  treatment  further  use  of  radium  is  inadvisable,  as  it  will  only  aggravate 
the  difficulty.  We  have  seen  several  cases  of  vesical  fistula  resulting  from 
radium  treatment  in  which  every  evidence  of  the  disease  had  disappeared  by 
gross  and  microscopic  examination,  but  where  the  loss  of  tissue  from  the  vesico- 
vaginal septum  was  very  great.  In  one  of  these  cases  we  were  able  to  close  the 
fistula  by  operation. 

In  cases  in  which  from  ulceration  of  the  disease  a  fistula  is  imminent  radium 
is  not  to  be  used,  for  the  fistula  is  very  promptly  established  and  further 
radium  treatment  becomes  no  longer  feasible. 

Details  of  Radium  Treatment  for  Cancer  of  the  Cervix. — The  use  of  radium  in 
the  treatment  of  cervical  cancer  is  still  in  the  experimental  stage,  hence  there 
are  no  very  definitely  standardized  rules  for  its  application.  Space  does  not 
permit  of  a  full  description  of  the  methods  employed  by  the  most  reliable  opera- 
tions and  such  a  description  would  present  so  many  variations  that  it  would 
cause  confusion  to  the  beginner  who,  having  secured  the  control  of  a  certain 


356  GYNECOLOGY 

amount  of  radium,  desires  some  well-defined  basis  for  his  initial  treatments. 
We  shall,  therefore,  present  the  general  rules  which  we  have  adopted  in  our  per- 
sonal work.  Only  a  few  institutions  and  individuals  are  fortunate  enough  to 
have  acquired  sufficient  radium  to  employ  the  emanations.  In  the  treatment 
of  large  numbers  of  patients  and  probably  also  in  the  application  to  individual 
cases,  radium  emanations  are  superior  to  the  radium  salts  more  commonly  used. 
The  employment  of  emanations,  however,  requires  an  outfit  too  expensive  for 
the  average  hospital,  as  well  as  the  services  of  an  expert  physicist.  We  shall 
omit  a  discussion  of  this  important  part  of  the  subject  and  confine  ourselves 
to  describing  the  direct  application  of  the  radium  salts  which,  on  account  of  the 
recently  increased  production  of  radium,  have  become  available  for  many  insti- 
tutions and  individuals. 

In  securing  radium  for  the  treatment  of  cervical  cancer  the  minimum  amount 
required  is  50  mg.,  while  for  use  in  single  applications  the  maximum  need  not 
exceed  100  mg.  The  most  convenient  form  in  which  to  purchase  the  radium  is 
in  three  tubes,  one  containing  50  mg.  and  two  containing  25  mg.  each.  By  having 
the  radium  in  separate  tubes  not  only  may  the  dosage  be  more  easily  regulated, 
but  when  feasible  the  tubes  may  be  so  distributed  in  relation  to  the  tissue  to  be 
treated  that  a  cross-fire  effect  may  be  attained. 

In  applying  radium  the  question  of  screening  is  of  very  great  importance. 
Radium  in  the  form  of  radium  bromid,  as  it  is  usually  put  out  commercially,  is 
tightly  packed  in  small  glass  cylinders  which  are,  in  turn,  incased  in  silver  or 
platinum  tubes.  The  metal  tubing  acts  both  to  protect  the  radium  from  loss 
and  to  screen  off  the  soft  alpha  and  beta  rays,  which,  as  has  been  noted  above, 
are  injurious  to  the  tissues.  More  complete  screening  of  the  soft  rays  may  be 
secured  by  still  further  encasing  the  silver  tubes  in  brass  or  lead.  It  has  been 
shown  that  gamma  rays  emerging  from  a  metal  screen  set  up  secondary  beta 
rays  which  are  as  destructive  to  tissues  as  the  primary  beta  rays.  These  second- 
ary beta  rays,  though  possessing  penetrating  power  equal  to  that  of  the  primary 
radiations,  are  endowed  with  much  less  absolute  energy  and  may  be  effectively 
obstructed  by  such  materials  as  paper,  cloth,  or  rubber.  It  is  customary,  there- 
fore, to  protect  the  tissues  still  further  by  enclosing  the  metal  receptacle  of  the 
radium  in  gauze  and  pure  rubber  (see  Part  III  for  technic) . 

The  dosage  of  a  given  radium  application  is  usually  estimated  in  terms  of 
milligram  hours  (mg.  hrs.),  computed  by  multiplying  the  number  of  milligrams 
used  by  the  number  of  hours  appl'ed.  Thus  a  dosage  of  2000  mg.  hrs.  may  rep- 
resent the  application  of  100  mg.  for  twenty  hours  or  of  50  mg.  for  forty  hours. 
We  have  not  adopted  this  method  of  designating  the  dosage,  for  it  is  extremely 
doubtful  if  the  effect  on  the  tissues  of  a  large  quantity  of  radium  for  a  short 
time  is  the  same  as  that  of  a  small  quantity  apphed  for  a  long  time,  even  though 
the  number  of  milligram  hours  may  be  equivalent.  This  is  a  problem  that  has 
not  yet  been  accurately  worked  out.  We  therefore  prefer  stating  the  dosage  in 
terms  both  of  quantity  of  radium  and  time-length  of  exposure. 


NEW    GROWTHS  357 

Having  determined  to  employ  radium  in  treating  a  properly  selected  case  of 
cervical  cancer,  the  operator  is  met  with  the  important  question  of  dosage. 
On  this  subject  the  profession  is  very  much  in  the  dark,  as  is  evidenced  by  the 
wide  variation  in  opinions  regarding  it.  There  is  very  little  information  as  to 
how  to  adapt  the  amount  and  time  of  exposure  to  the  individual  case.  If  this 
phase  of  the  subject  were  understood  we  should  doubtless  have  an  explanation  of 
why  in  one  case  the  disease  responds  magically  to  treatment,  while  in  an  ap- 
parently similar  case  with  hke  treatment  the  effect  is  either  neutral  or  even 
disastrous.  Space  does  not  allow  a  full  discussion  of  this  subject.  We  have 
intimated  above  that  variations  in  the  histologic  structure  may  account  to  some 
extent  at  least  for  differences  in  the  results  of  treatment.  Possibly  the  differences 
are  due  to  individual  tissue  resistance  to  the  action  of  the  rays. 

In  prescribing  radium  for  cervical  cancer  one  must  always  bear  in  mind  that 
the  substance  may  be  a  powerful  agent  for  the  destruction  of  normal  tissues 
surrounding  the  diseased  area.  That  this  is  an  everpresent  danger  even  with  the 
most  careful  screening  is  evidenced  by  the  huge  fistulse  that  occasionally  occur 
even  in  clinics  conducted  by  experienced  operators.  These  fistulse  may  not 
appear  until  weeks  or  months  after  an  application,  so  that  a  case  which  at  first 
appears  eminently  successful  may  in  time  prove  a  distressing  failure  even  though 
the  disease  may  have  temporarily  vanished. 

In  order  to  avoid  destructive  results  not  only  must  the  most  painstaking 
care  be  exercised  in  protecting  the  normal  tissues,  but  conservatism  must  be 
observed  both  in  the  dosage  and  frequency  of  application.  In  our  own  prac- 
tice we  are  accustomed  to  regard  as  a  maximum  close  100  mg.  for  twenty- 
four  hours  or  2400  mg.  hrs.  This  is  doubtless  a  conservative  lunit,  for  some 
operators  extend  their  maxmum  to  a  point  considerably  beyond  this.  There  is 
some  evidence  that  a  maximum  dosage  attained  by  employing  a  large  amount  of 
radium  with  a  shorter  time  exposure  is  more  efficacious  against  the  cancer  cells 
and  less  dangerous  to  the  normal  tissue  than  a  long  exposure  with  a  small  amount 
of  radium. 

In  giving  a  first  treatment  to  the  average  case  we  usually  employ  the  maximum 
dosage  above  mentioned,  i.  e.,  100  mg.  for  twenty-four  hours.  If  the  case  is 
manifestly  inoperable  it  is  a  safe  plan  to  follow  the  dictum  of  Clark,  who  recom- 
mends that  no  further  treatment  be  given  until  the  lapse  of  six  weeks,  when  the 
same  dosage  is  repeated.  If  improvement  is  not  shown  after  two  such  treatments 
there  is  little  use  of  further  attempts.  Most  operators  repeat  the  applications 
more  frequently.  Thus  Frank  recommends  the  following  schedule:  The  second 
treatment  seven  to  ten  days  after  the  first;  the  third  treatment  fourteen  days 
after  the  second.  If  improvement  is  shown,  two  more  treatments  are  given 
three  weeks  apart.  The  radium  is  given  in  diminishing  amounts,  the  total 
dosage  for  the  five  treatments  averaging  6000  mg.  hrs.  Two  or  three  applica- 
tions one  month  apart  with  modified  dosage  are  added  to  the  five  primary 
applications. 


358  GYNECOLOGY 

The  methods  of  Clark  and  Frank  may  be  regarded  as  the  extremes.  Our 
personal  experience  has  led  us  to  recommend  the  conservatism  of  Clark  in  most 
cases.  Frequent  apphcations  sometimes  produce  very  rapid  and  brilliant  re- 
sults, but  there  is  greater  danger  of  injury  to  the  normal  tissues.  Vesical  and 
rectal  tenesmus  following  a  given  treatment  constitute  a  serious  warning  that  the 
radiation  has  produced  some  injury  in  the  tissues  surrounding  those  organs. 
After  such  a  danger  signal  caution  must  be  exercised  both  in  the  matter  of  later 
dosage  and  in  repeating  the  treatment  too  soon.  Inasmuch  as  the  destruction  of 
normal  tissues  is  the  result  of  imperfect  protection  we  are  accustomed  to  make 
most  of  our  applications  with  the  patient  fully  anesthetized.  In  this  way  the 
various  protective  measures,  described  in  the  section  on  Technic,  may  be  carried 
out  with  much  greater  precision. 

When  a  case  is  presented  in  which  there  is  a  large  cauliflower  mass  in  the 
vagina  the  question  arises  as  to  whether  it  is  better  to  curet  the  mass  first  or  to 
apply  the  radium  at  once  and  to  depend  on  it  for  the  removal  of  the  growth.  It 
is  entirely  possible  to  cause  such  a  growth  to  melt  away  by  frequent  apphcations 
of  radium.  We  do  not,  however,  recommend  this  method,  for  as  the  growth 
extends  well  down  into  the  vagina  it  is  difficult  to  apply  the  radium  without 
exposing  too  much  the  normal  vaginal  wall.  We  advise,  therefore,  that  the  ex- 
crescent mass  be  first  hghtly  removed.  The  curet,  if  used,  should  not  be  carried 
too  deeply,  for  the  object  is  merely  to  remove  a  mechanical  obstruction  to  the 
apphcation  of  the  radium.  The  radium  may  be  inserted  at  the  time  that  the 
cureting  is  done.  In  many  cases  the  curet  is  not  necessary,  as  the  mass  may  be 
removed  sufficiently  with  the  finger.  If  this  can  be  done  it  is  preferable  to  usmg 
the  curet. 

If  the  case  to  be  treated  offers  any  possible  hope  of  later  operability  the  treat- 
ment should  be  definitely  directed  to  that  end.  The  maximum  dosage  is  ffi-st 
given.  The  patient  should  then  be  examined  frequently  and  the  condition  of  the 
parametria  noted.  In  an  ideal  case  in  which  there  is  a  prompt  response  to  the 
initial  treatment  the  patient  would  be  ready  for  operation  in  about  three  weeks 
after  the  ffi-st  apphcation.  If  the  operation  can  be  performed  at  that  time  it  wiU 
be  found  that  the  one  treatment  has  not  seriously  affected  the  parametria  and  that 
the  operation,  though  more  difficult,  may  be  carried  out,  for  the  most  part,  with 
the  usual  technic. 

If  at  the  end  of  three  weeks  the  condition  shows  improvement  but  the  case  is 
still  inoperable  it  is  our  practice  to  give  another  treatment  of  half  the  maximum 
dosage  (100  mg.,  twelve  hrs.)  instead  of  waiting  for  the  usual  six  weeks'  interval 
as  recommended  by  Clark.  It  may  be  necessary  to  give  still  another  treatment 
with  modified  dosage  three  weeks  after  the  second.  At  least  three  weeks  should 
elapse  after  a  treatment  before  operation  is  undertaken.  It  has  been  our  experi- 
ence that  the  greater  the  number  of  radium  treatments,  the  more  difficult  the 
operation.     We  have  also  noted  that  even  after  an  apparently  successful  radium 


NEW    GROWTHS  359 

treatment  and  later  operation  a  fistula  may  become  established  weeks  or  months 
later,  especially  if  a  recurrence  takes  place.  This  we  ascribe  to  a  divitalization 
of  the  normal  tissues  induced  by  the  initial  radium  treatments  and  possibly 
preventable  by  more  complete  protection  at  the  time  of  applying  the  radium. 

The  prophylactic  use  of  radium  after  a  radical  operation  requires  special  care. 
Our  observations  indicate  that  postoperative  cases  are  especially  susceptible  to 
fistula  formation.  Some  operators  leave  radium  in  the  vaginal  wound  as  a 
routine  measure  in  completing  a  radical  operation.  This  procedure  we  do  not 
recommend,  as  radium  is  especially  destructive  when  applied  to  freshly  cut 
tissues.  If  radium  is  to  be  used  as  a  prophylactic  we  prefer  to  apply  it  after  the 
vaginal  wound  is  completely  healed,  and  then  only  in  modified  doses  of  at  least 
four  to  six  weeks'  intervals.  Conservatism  in  this  respect  is  especially  urged,  for 
the  welfare  of  a  patient  who  has  been  cured  of  a  cancer  of  the  cervix  cannot  be 
said  to  be  greatly  improved  if  the  final  result  is  a  permanent  vesical  or  rectal 
fistula. 

In  making  applications  of  radium  for  local  recurrences  in  the  vagina  the  same 
care  must  be  exercised  as  in  employing  radium  as  a  prophylactic  in  the  healthy 
vagina,  for  in  recurrent  cases  the  danger  of  causing  fistulse  is  even  greater.  If 
the  recurrence  is  discovered  early  one  treatment  often  suffices  to  cause  the 
disease  to  disappear.  In  a  case  of  this  kind  a  maximum  close  should  not  be 
given.  We  are  accustomed  to  use  50  to  100  mg.  from  four  to  twelve  hours, 
depending  on  the  condition  of  the  vaginal  tissue  and  progress  of  the  disease. 
That  is  to  say,  for  a  small  nodule  in  unimpaired  tissue  the  dosage  would  be  greater 
than  for  a  recurrence  with  ulceration.  In  the  latter  case  a  smaller  dosage  would 
be  used  and,  if  necessary,  repeated  at  a  later  date. 

In  cases  of  metastatic  extension  into  the  regional  lymph-glands  radium,  in 
our  experience,  has  failed  either  to  check  the  progress  of  the  disease  or  effectually 
to  control  the  pain. 

As  to  the  after-treatment  of  patients  treated  by  radium  for  cervical  cancer 
there  is  not  much  to  be  said.  The  average  stay  in  the  hospital  is  from  three  to 
seven  days,  depending  on  the  amount  of  constitutional  reaction.  Many  patients 
show  absolutely  no  general  effects  from  the  treatment.  In  others,  especially  in 
those  much  depleted  by  the  disease,  various  reactions  appear,  chiefly  in  the 
form  of  nausea  and  vomiting,  which  may  persist  for  two  or  three  days.  Sometimes 
it  lasts  only  while  the  treatment  is  in  process  and  disappears  as  soon  as  the 
radium  is  removed.  Rectal  or  vesical  tenesmus  may  sometimes  become  a  dis- 
turbing sj^mptom  and  may  persist  for  several  weeks,  requiring  sedative  or  even 
local  treatment.  Patients  suffering  a  reaction  of  this  kind  are  in  danger  of 
developing  a  fistula  later.  It  can  usually  be  avoided  by  lead  protection  of  the 
vaginal  walls  and  close  packing  with  gauze. 

The  occurrence  of  leukorrhea  following  operation  is  a  matter  of  considerable 
variation  and  doubtless  depends  on  the  nature  of  the  growth  and  the  amount  of 


360  GYNECOLOGY 

dosage.  In  some  cases  the  secretion  is  very  profuse,  lasting  for  days  or  even  weeks, 
while  in  others  it  is  hardly  perceptible.  When  the  discharge  is  profuse  the  pa- 
tient should  be  carefully  nursed  and  given  douches  sufficient  in  number  to  keep 
the  vagina  as  clean  as  possible.  These  patients  should  be  kept  in  the  hospital 
until  the  discharge  is  under  control.  In  some  cases  there  is  a  rise  in  temperature 
as  a  result  of  toxic  absorption.  If  there  is  a  temperature  reaction  the  patient 
should  be  kept  under  observation  until  the  temperature  subsides,  for  the  rise 
may  indicate  an  inflammatory  pelvic  process  which  is  sometimes  induced  by 
the  action  of  the  radium.  If  a  pelvic  peritonitis  ensues  the  patient  should 
be  treated  by  non-operative  methods,  chief  reliance  being  placed  on  frequent 
hot  douches. 

Heat  Treatment. — To  J.  F.  Percy  the  profession  is  chiefly  indebted  for  a 
revival  of  the  method  of  treating  cervical  cancer  by  heat.  Many  years  ago 
Byrne  achieved  brilliant  results  by  this  method,  but  since  his  time  no  one  has 
been  able  to  repeat  his  success.  Percy  states  that  his  work  is  based  on  labora- 
tory experiments,  which  show  that  cancer  cells  cannot  be  successfully  trans- 
planted after  an  exposure  of  45°  C.  for  ten  minutes,  while  normal  tissue  cells 
can  stand  a  temperature  of  from  55°  to  60°  C.  without  being  devitalized.  The 
reason  that  the  use  of  heac  has  accomplished  so  little  in  the  treatment  of  cancer 
is  due  to  the  improper  manner  by  which  it  has  been  appHed. 

To  quote  Percy: 

"Experimental  work  has  shown  that  a  low  degree  of  heat  has  a  much  greater  penetrating 
power  in  a  mass  of  cancer  than  has  a  high  degree.  High  degrees  of  heat  carbonize  the  tissues, 
mhibiting  penetration;  low  degrees  of  heat  coagulate  the  tissues,  encouraging  heat  dissemina- 
tion. High  degrees  of  heat,  with  the  resulting  carbon  core,  prevent  drainage  in  the  cancer 
mass.  This  permits,  in  a  certain  number  of  cases,  the  absorption  of  an  excessive  quantity  of 
broken-down  cancer  cells,  which  are  dangerous  to  the  Ufe  of  the  patient.  When  the  temperature 
in  the  heating  iron  is  the  right  degree  for  the  greatest  penetration,  its  shank  can  be  wrapped  with 
surgeon's  cotton  and  remain  there  for  forty  minutes  or  more.  The  color  or  texture  of  the  cotton 
will  not  be  altered  in  any  way  by  this  degree  of  temperature;  and  this  merely  emphasizes  the 
fact  that  a  burning  temperature  is  not  used." 

It  will  thus  be  seen  that  this  procedure  is  in  no  sense  a  burning  or  cauteriza- 
tion of  the  parts,  for  this,  according  to  Percy,  "only  defeats  the  effort  to  get  a 
maximum  penetration  of  heat."  Among  the  advantages  claimed  for  this 
method  is  the  freedom  from  danger  of  injuring  the  rectum,  bladder,  and  ureters; 
and  the  quick  sealing  of  the  lymphatics  and  blood-vessels,  which  not  only  pre- 
vents further  dissemination  of  the  disease,  but  is  a  safeguard  against  the  spread 
of  infection. 

Percy's  operation  consists  essentially  in  applying  electrically  heated  irons 
wrapped  in  cotton  to  the  cancerous  field.  The  irons  are  kept  at  a  carefully 
regulated,  moderate  temperature,  being  introduced  through  a  specially  devised 
water-cooled  vaginal  speculum.  The  length  of  time  required  for  application 
to  a  certain  part  is  determined  by  an  assistant,  who,  through  an  abdominal  open- 
ing, grasps  the  malignant  mass  and  announces  when  the  heat  is  approaching  a 


NEW    GROWTHS  361 

danger  point.  By  this  method  the  gross  mahgnant  mass  is  usually  removed  at 
one  sitting.  Repeated  operations  are  sometimes  necessary.  For  a  detailed 
description  of  the  technic  of  application  of  Percy's  cautery  see  Part  III. 

This  work  is  too  recent  to  permit  of  definite  reports  as  to  curabihty,  but, 
considering  the  former  excellent  results  of  Byrne,  the  method  possesses  con- 
siderable promise.^ 

Palliative  Treatment  of  Cancer  of  the  Cervix. — WHaen  a  case  of  cancer  of  the 
cervix  is  found  to  be  inoperable,  and  radium  or  the  heat  treatment  is  not  avail- 
able, the  first  indication  is  to  remove  the  sloughing  necrotic  part  of  the  disease, 
for  from  this  friable,  infected  tissue  the  patient  is  bleeding  and  absorbing  toxic 
substances  that  produce  the  cachexia,  loss  of  weight,  fever,  and  other  general 
constitutional  sjTiiptoms.  The  removal  of  this  tissue  consists  of  a  thorough 
cureting  down  as  nearly  as  possible  to  normal  tissue,  followed  by  deep  cauteriza- 
tion. This  procedure  must  always  be  carried  out  with  care  not  to  perforate  the 
uterus,  an  accident  that  is  especially  liable  to  happen  in  cureting  infiltrating 
cancer  of  the  posterior  lip,  in  which  there  is  danger  of  entering  Douglas'  fossa, 
This  is  almost  invariably  followed  by  fatal  peritonitis. 

Curetment  and  cauterization,  as  a  rule,  produce  a  marked  general  im- 
provement  in  the  patient's  health.  Bleeding  is  temporarily  checked,  while 
the  nauseating  discharge  is  made  less  watery  and  abundant,  and  the  foul  odor 
is  stopped  or  lessened  for  a  time.  The  general  appearance  of  the  patient  is 
improved,  and  there  is  sometimes  some  gain  in  weight,  while  the  general  mental 
depression  is  relieved. 

The  patient  must  be  kept  on  frequent  douches  of  formalin  (1  per  cent.) 
to  control  the  odor.  After  a  time,  as  the  disease  again  grows,  the  old  symptoms 
retm'n  and  the  cureting  and  cauterization  must  be  repeated,  and  so  on  until 
the  patient  dies.  After  a  time  severe  boring,  unbearable  pain  ensues.  This 
can  best  be  treated  at  first  with  frequent  doses  of  dionin,  for  which  in  the  later 
stages  morphin  must  be  substituted  in  amounts  large  enough  and  frequent 
enough  to  keep  the  patient  comfortable. 

Other  paUiative  operations  are  sometimes  used  besides  curetment  and  cau- 
terization.     Kronig,  after  performing  an  "exploratory  laparotomy"  and  find- 

^  Since  the  above  was  written  the  Percy  cauterj'  has  been  extensively  tried  out  in  this  country. 
Opinions  as  to  its  value  vary  considerably,  but  the  most  reliable  evidence  is  in  its  favor,  as  is  also  the 
result  of  our  own  experience.  There  is  no  doubt  that  this  method  of  treatment  requires  skill  and 
experience  in  order  to  avoid  certain  disastrous  complications.  Of  these,  the  most  important  is  the 
fatality  associated  with  ulcerations  of  the  intestinal  tract  similar  to  that  which  may  occur  after 
extensive  cutaneous  burns.  Other  complications  are  the  formation  of  fistuls3,  the  occurrence  of  a 
late  secondary  hemorrhage,  and  septic  intoxication  from  sloughing  tissues.  According  to  Smith,  the 
fistulse  usually  heal  spontaneously  in  contrast  to  the  fistulge  following  radium,  which  practically 
never  heal.  The  secondarj^  hemorrhages  may  be  avoided  by  ligating  the  internal  iliac  and  OA'ariau 
vessels  at  the  time  of  the  operation.  If  this  precaution  is  not  taken  secondary  hemorrhages  occur  in 
40  per  cent  of  cases. 

The  most  complete  report  on  the  use  of  the  Percy  cauterj'  has  been  made  by  Smith,  who 
records  100  cases  treated  at  the^Mayo  Clinic.  Of  these  it  was  possible  later  to  perform  a  radical 
extirpation  of  the  uterus  in  26  cases,  the  time  chosen  for  the  hysterectomy  being  about  four  weeks 
after  the  cautery  treatment.  In  19  of  the  26  cases  thus  operated  on  no  carcinoma  was  found  in  the 
specimen  removed  at  the  final  operation. 

Smith's  results  compare  favorably  mth,  if  they  do  not  surpass,  the  best  reports  from  the  use 
of  radium  in  the  same  class  of  cases. 


362  GYNECOLOGY 

ing  the  case  inoperable,  ties  the  hypogastric,  ovarian,  and  round  Hgament  arte- 
ries. This  seems  to  delay  the  progress  of  the  disease  somewhat  and  prevents 
bleeding  for  a  considerable  time  until  a  collateral  circulation  is  estabhshed. 

Chlorid  of  zinc,  applied. to  the  crater  in  the  uterus  made  by  the  cureting 
and  cautery,  has  been  much  used.  It  is  sometimes  valuable  when  applied 
by  skilled  hands,  but  its  effect  on  the  tissues  is  difficult  to  control,  and  there 
is  always  danger  of  perforation  of  the  uterus  or  erosion  of  the  uterine  vessels. 
It  is  best  apphed  on  small  pledgets  of  cotton,  which  are  packed  into  the  cavity. 
At  the  end  of  about  a  week  the  pieces  of  cotton  may  be  removed  en  masse  with  a 
complete  cast  of  the  cavity  adherent.  Chlorid  of  zinc  is  not  recommended  as  a 
routine  measure. 

An  excellent  palliative  measure  for  the  control  of  the  discharge  and  allevia- 
tion of  the  foul  odor  is  the  employment  of  acetone,  as  recommended  by  Gellhorn : 

The  patient  hes  on  her  back  with  hips  elevated  by  pillows.  Through  a  Fergu- 
son's speculum  3  or  4  drams  of  pure  acetone  are  introduced  into  the  vagina  and 
left  in  contact  with  the  diseased  area  for  about  four  minutes.  The  acetone  is  then 
removed  by  pledgets  of  absorbent  cotton  and  a  glycerin  tampons  packed  in  the 
vagina  to  be  removed  in  twenty-four  hours. 

It  is  important  to  avoid  allowing  the  acetone  to  come  in  contact  with  the 
external  skin,  as  it  causes  intense  burning  pain. 

Another  less  effectual  means  of  keeping  the  vagina  clean  is  the  frequent 
application  of  iodin  to  the  diseased  area. 

Under  careful  palhative  treatment  patients  may  live  from  one  to  two  years. 

Unquestionably  the  best  palhative  treatment  for  inoperable  and  recurrent 
cases  is  that  afforded  by  radium.  On  account  of  the  hmited  supply  of  radium 
and  the  lack  of  knowledge  of  its  use  the  treatment  at  present  is  restricted  to 
a  few  fortunate  localities.  It  is  necessary,  therefore,  in  the  majority  of  cases  to 
resort  to  the  older  time-honored  methods  for  palliative  treatment. 

CANCER  OF  THE  BODY  OF  THE  UTERUS 

We  prefer  to  treat  the  subject  of  cancer  of  the  uterine  body  separately  from 
that  of  the  cervix,  because  the  two  diseases  are  quite  distinct  both  in  their  chn- 
ical  aspects  and  in  their  pathologic  processes. 

The  anatomic  type  of  cancer  of  the  body  is  invariably  that  of  adenocarci- 
noma, although  the  process  may  develop  into  advanced  stages  in  which  the 
glandular  arrangement  is  no  longer  apparent.  The  histologic  picture  may  then 
be  one  of  carcinoma  simplex,  in  which  the  carcinomatous  cells  are  massed  to- 
gether with  no  definite  arrangement.  Sometimes  a  metaplasia  takes  place, 
Hke  that  which  frequently  appears  in  cancer  of  the  endocervix,  whereby  the 
cells  take  on  a  squamous  character,  even  to  the  formation  of  cornified  pearls.- 

The  growth  originates  in  the  mucous  membrane,  and  tends  both  to  pro- 
liferate into  the  uterine  cavity  and  to  infiltrate  the  muscular  wall  of  the  uterus, 
one  of  these  tendencies  usually  predominating.  In  the  typical  case  that  is 
growing  toward  the  uterine  cavity  the  microscopic  appearance  is  that  of  long- 
branching  tendrils  of  a  papillary  nature.     When  the  disease  encroaches  on  the 


NEW    GROWTHS 


363 


^fjv-fy^ 


^^Jdr">-.^ 


Fig.  111. — Adenocarcinoma  of  the  Body  of  the  Uterus. 
The  disease  is  beginning  in  the  upper  part  of  the  canal  and  is  extending  both  inward  into  the  mus- 
cular wall  and  outward  toward  the  canal.     In  this  case  the  growth  has  a  papillary  appearance. 


\s    _  Vvinb\jS 


"Vcvoxwo.--' 


^^  V:C=.-c(XV5t&,iqv^ 


Fig.  112 — Adenocarcinoma  Beginning.  Near  the  Internal  Os. 
This  tumor  has  metastasized  in  the  ovaries. 


364 


GYNECOLOGY 


muscular  wall  glandular  offshoots  are  seen  invading  the  muscle  below  the 
normal  line  of  demarcation,  between  muscle  and  endometrium.  Macroscopic- 
ally,  upon  opening  the  uterine  cavity  the  growth  appears  as  an  irregular  eleva- 
tion of  the  endometrium,  the  surface  of  which  in  some  places  may  be  smooth 
and  wavy,  in  others  papillomatous.  The  cut  surface  is  usually  somewhat  lighter 
in  color  than  that  of  the  normal  uterine  tissue,  and  a  rather  distinct  outline  can 
be  made  out  between  cancer  and  muscle  tissue.  The  disease  gradually  en- 
croaches on  the  uterine  wall  until  in  advanced  cases  the  musculature  may  be 
little  in  evidence.     In  the  course  of  time  it  may  break  through  the  outer  wall 


Fig.  113. — Hydhometra. 
In  this  case  the  patient,  aged  sixty- two  at  the  time  of  operation,  had  never  menstruated,  though 
in  earlier  life  she  had  had  periodic  molimina.  The  tumor  seen  in  the  cavity  is  a  papillary  adeno- 
carcinoma, probably  of  recent  developmcDt.  The  contents  of  the  uterine  cavity  were  of  a  serous 
character  with  brownish  tinge.  The  outline  of  the  cervix  has  been  sketched  in  to  show  the  absence 
of  a  complete  canal.  The  operation  consisted  of  a  supravaginal  hysterectomy,  the  cystic  nature  of 
the  uterus  not  being  discovered  until  the  specimen  was  opened. 

and  become  disseminated  to  neighboring  parts.  Unlike  cancer  of  the  cervix,  it 
usually  does  not  invade  the  parametrium  excepting  by  direct  extension,  a 
process  which  indicates  a  late  stage  of  the  disease.  Metastasis  to  the  regional 
lymph-glands  is  later  than  in  cancer  of  the  cervix.  Occasionally  cancer  of  the 
body  metastasizes  to  the  tube  and  ovary  in  a  comparatively  early  stage  of  its 
growth,  an  extension  rarely  seen  in  cancer  of  the  cervix. 

Cancer  of  the  body  has  its  principal  incidence  later  in  life  than  cancer  of  the 
cervix,  the  figures  of  Koblanck  showing  that  in  50  per  cent,  of  cases  it  occurs 
between  the  ages  of  fifty  and  sixty.     It  is  quite  rare  to  find  it  in  patients  under 


Fig.  114. — Pedunculated  Adenocarcinoma  of  Body  of  Uterus. 


Fig.  115. — Adenocarcinoma  of  the  Endometrium. 
High  power.     The  distinctive  feature  is  the  glands,  the  epithelium  of  which  has  proliferated  until 
the  lumens  are  obhterated.     The  epithelial  cells  are  large,  vary  in  size,  and  on  the  right  especially 
appear  like  squamous  epithelial  carcinoma.     Well-formed  glands,  however,  are  seen  in  other  places 
with  thin  trabeculse  of  stroma  between  them. 


365 


366  GYNECOLOGY 

forty.  It  is  seen  only  about  one-eighth  as  often  as  cancer  of  the  cervix,  accord- 
ing to  statistics. 

Nulliparous  women  seem  to  have  a  special  predisposition  to  this  form  of 
cancer,  a  fact  that  still  further  differentiates  it  from  cervical  cancer. 

Cancer  of  the  body  is  quite  often  found  in  association  with  uterine  fibroids, 
whereas  the  combination  of  fibroids  with  cancer  of  the  cervix  is  comparatively 
rare.  As  the  process  frequently  originates  in  the  mucous  membrane  covering 
the  myoma,  it  is  thought  that  the  cancerous  growth  is  stimulated  by  trauma 
exerted  by  the  fibroid  on  the  overlying  endometrium. 


^$^-  .^ /  V ^  ,%o.C'     ^*  /^^®^;^« ^^r f  ^  ■C'^  */-a«#i  «t%:^  ^^^'% ^^ 


s  ...  ^«*:.  .'-,\>,  "^t    .J4  ji  fj-  4..^  .JA"'*>  z  '*  '^?^£&- 


7Put.fl  O  Hui^i,-r(5A'i.^^^ 
Fig.  116. — Adenocarcinoma  of  the  Endometrium.  "-^ 

High  power.  To  illustrate  the  growth  of  the  epithelial  cells  outward  from  the  gland,  as  is  seen  in 
the  upper  left  two-thirds  of  the  drawing.  The  gland  seen  has  lost  its  basement-membrane  and  lies 
in  a  mass  of  carcinoma  tissue.  To  the  lower  right  is  a  strand  of  stroma  which  has  become  separated 
from  the  tumor  in  cutting  the  section. 

Cancer  of  the  body  is  especially  favorable  from  a  surgical  standpoint  be- 
cause not  only  is  its  progress  slow,  but  it  usually  gives  early  warning  of  its  pres- 
ence. It  makes  its  appearance  first  by  increased  uterine  secretion  and  then  by 
bleeding.  This  bleeding,  coming  as  it  frequently  does  after  the  menopause, 
attracts  the  immediate  attention  of  the  patient,  so  that  she  is  apt  to  seek 
medical  advice  in  time  for  successful  surgical  treatment.  When  the  disease 
occurs  before  the  menopause  its  detection  from  clinical  symptoms  is  more  diffi- 
cult.    The  bleeding  at  this  time  is  apt  to  appear  only  as  a  profuse  menstrual 


NEW    GROWTHS 


367 


period,  and  the  mistake  is  often  made,  both  by  the  patient  and  her  doctor,  of 
regarding  the  menstrual  disturbance  merely  as  an  indication  of  the  change  of 
life.  The  progress  of  the  disease,  however,  is  usually  so  slow  that  the  persistent 
hemorrhages  finally  excite  suspicion  in  time  for  surgical  cure.  When  a  cancer 
of  the  body  is  associated  with  a  uterine  fibroid  the  bleeding  has  no  definite 
diagnostic   characteristic  which  would  differentiate  it  from  that  seen  in  an 


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'-^ $&'■■, 


«f  «*  <j  \  t 


cO, 


^Vt 


f  ©e,,S' 


Fig.  117. — Adenocarcinoma  of  the  Endometrium. 
High  power.     To  illustrate  the  increase  in  number  of  the  glands  which  lie  close  together  and  are 
irregular  in  outline.     The  epithelial  cells  have  lost  their  regular  placing,  appear  to  be  jumbled  to- 
gether, occur  in  more  than  one  layer,  and  contain  nuclei  larger  than  normal  and  varying  much  in  size. 


ordinary  submucous  mj^oma.  If,  therefore,  in  a  case  of  bleeding  fibroid  non- 
operative  treatment  is  decided  *on  for  any  reason,  the  uterine  cavity  should  at 
least  be  explored  to  exclude  the  possibility  of  the  presence  of  a  cancer.  This 
procedure  is  especially  important  if  the  a;-ray  or  radium  is  to  be  used,  for 
there  seems  little  doubt  that  in  cases  of  myoma  complicated  by  carcinoma  or 
sarcomatous  degeneration  the  malignant  process  is  stimulated  to  new  activity 
by  the  influence  of  the  rays. 


368 


GYNECOLOGY 


The  diagnosis  of  cancer  of  the  body  should  always  be  made  by  the  micro- 
scopic examination  of  curetings.  In  a  great  many  cases,  where  the  uterus  is 
soft  and  the  cervix  is  patulous,  a  piece  of  the  endometrium  can  be  removed  by 
means  of  a  small  curet  without  anesthesia. 

Clinically,  cancer  of  the  body  must  be  differentiated  from  uterine  insuffi- 
ciency, mucous  polyps,  chronic  interstitial  endometritis,  cancer  of  the  cervix, 
and  submucous  fibroids,  and  the  only  sure  way  of  accompUshing  this  is  by  means 
of  the  microscope. 

Microscopic  differentiation  between  cancer  of  the  body  and  certain  benign 
conditions  of  gland  hyperplasia  of  the  endometrium  is  sometimes  difficult.     In 


Fig.  118. — Adenocarcinoma  of  the  Endometrium. 


gland  hyperplasia  there  is  often  a  suggestive  heaping-up  of  the  epithelial  cells 
lining  the  glands  and  an  excessive  branching  of  the  glands  themselves.  Occa- 
sionally, too,  there  is  a  dipping  of  the  glands  into  the  muscular  tissue  beyond 
the  normal  boundary  fine  of  the  endometrium.  These  eccentricities  of  non- 
malignant  hyperplasia  must  be  borne  in  mind,  and  not  be  interpreted  as  mani- 
festations of  malignancy  without  further  evidence.  The  final  diagnosis  of  cancer 
must  be  made  by  irregularities  of  the  cell  form,  by  abnormal  nuclear  figures,  by 
unevenness  in  the  staining  of  the  nuclei,  and  by  lack  of  continuity  in  the  basal 
membrane  of  the  glands. 


NEW    GROWTHS 


369 


^fMm§ 


Fig.  119. — Adenocarcinoma  of  the  Endometrium. 


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Fig.  120. — Adenocarcinoma  of  the  Endometrium. 
Low  power  to  show  a  papillary  outgrowth.     We  see  a  branching,  connective-tissue  stroma  carry- 
ing blood-vessels,  covered  with  epithelium  lying  in  one  to  several  layers.     This  is  characteristic  of 
the  advanced  adenocarcinoma  growing  out  into  the  uterine  cavity.       The  marked  change  can  be 
understood  if  this  is  compared  with  the  normal  endometrium. 
24 


370  GYNECOLOGY 

When  the  diagnosis  of  cancer  is  established  the  treatment  is  immediate 
radical  operation. 

The  operation  for  cancer  of  the  body  is  similar  to  that  for  cancer  of  the 
cervix,  except  that  it  need  not  be  so  extensive.  Removal  of  lymph-glands 
is  rarely  necessary,  while  a  wide  dissection  of  the  parametrium  is  not  required 
in  most  cases.  Moreover,  as  cancer  of  the  body  has  little  tendency  to  extend 
downward,  there  is  not  the  need. of  removing  the  upper  part  of  the  vagina  as 
there  is  in  operating  for  cancer  of  the  cervix.  The  operation  for  cancer  of  the 
body,  therefore,  is  very  much  less  difficult  than  that  for  cervix  cancer,  and  the 
primary  mortality  is  correspondingly. lower. 

The  prognosis  as  to  recurrence  is  very  good,  and  permanent  cures  should  be 
obtained  in  at  least  80  per  cent,  of  cases  operated  on. 

CHORIO-EPITHELIOMA   MALIGNUM 

This  term  is  applied  to  a  malignant  tumor  that  develops  from  the  epithelial 
elements  of  placental  tissue.  It  most  commonly  follows  the  expulsion  of  a 
hydatidiform  mole,  but  may  date  its  origin  from  an  abortion  or  a  tubal  preg- 
nancy, or  even  a  normal  pregnancy.  The  tumor  usually  appears  first  as  a  nodu- 
lar excrescence  growing  from  the  surface  of  the  uterine  canal  or  from  the  lumen 
of  the  tube.  The  growth  is  very  vascular,  often  having  the  appearance  of  a 
hematoma,  and  tends  to  bleeding  and  necrosis.  Metastases  soon  appear  on 
the  wall  of  the  vagina  or  in  the  neighboring  pelvic  organs,  and  spread  rapidty 
by  the  blood  circulation  to  distant  parts  of  the  body,  especially  to  the  lungs. 
The  disease,  if  not  checked  by  surgical  interference,  is  usually  very  fatal,  destroy- 
ing the  patient  with  extraordinary  rapidity,  but  sometimes  abruptly  ceases  in 
its  progress  even  after  the  appearance  of  distant  metastases.  Its  onset  may 
follow  the  abortion  or  mole  from  which  it  takes  its  origin  almost  immediately, 
or  it  may  not  appear  for  days,  months,  or  even  years  later. 

The  history  of  our  present  knowledge  of  chorio-epithelioma  is  one  of  unusual 
interest.  The  disease  was  first  described  by  Saenger  less  than  twenty-five  years 
ago.  He  thought  that  these  tumors  developed  from  the  decidual  cells  of  the 
endometrium,  and  gave  the  name  deciduoma  to  the  disease,  supposing  it  to  be  a 
sarcoma.  Later,  Marchand  described  the  histology  more  exactty,  and  showed 
that  the  tumor-growth  develops  from  the  epithelial  cells  surrounding  the  chorionic 
viUi,  and  is,  therefore,  a  carcinoma.  This  view  is  universally  held  at  present, 
and  all  terms  formerly  used  at  different  times  to  designate  the  disease  have 
given  way  to  the  name  suggested  by  Marchand,  "chorio-epithelioma,"  which 
best  describes  its  histogenesis. 

There -has  also  been  a  complete  change  in  our  knowledge  of  the  clinical  course 
of  these  tumors  quite  as  remarkable  as  that  of  our  ideas  as  to  their  histology. 
Saenger's  first  5  cases  died  with  general  metastases  within  seven  months  after 
abortion,  and  he  regarded  the  disease  as  absolute^  hopeless.     In  1896  Apfel- 


NEW    GROWTHS 


371 


staedt  stated  that  all  therapy  against  these  most  malignant  of  all  known  neo- 
plasms was  madness.  Nevertheless,  six  years  later  Polano  reported  50  per  cent. 
and  Teacher  reported  63.3  per  cent,  of  cures. 

Although  these  percentages  are  today  regarded  as  unduly  high,  3'et  the 
number  of  operative  cures  is  very  large,  while  numerous  instances  have  been 
reported  where  tumor  masses  which  had  been  left  behind  during  incomplete 
operations  have  eventually  healed  spontaneously.     We  see,  therefore,  the  great- 


■:'.'■'..  'S  •^  .■;> 


.,1,'r !  ■'■  •' 


>-;rsc^,v:(^. 


.•V":,- 


:kv?^'-  ■: 


-^/;      f  ••;^v^;^'js*l 


y^ 


.    r      .',•!•    .'•  .      •    /•    IV,      ;'/■••'     ••.  •  (..  •'      iff'    -••-•,-- 


r  y-l 


Fig.  121. — Retained  Placenta,  Infected. 
Low  power.     The  section  consists  mostly  of  coagulated  blood.     The  strands  of  fibrin  show 
especially.     Infiltrating  it  are  large  numbers  of  leukocytes,  mostly  of  the  polynuclear  variety.     Near 
the  top  and  in  the  center  are  several  chorionic  villi. 

est  contrasts  in  the  clinical  picture  of  different  cases,  ranging  from  the  stormiest 
and  most  malignant  course  to  spontaneous  and  permanent  retrogression. 

The  first  instances  of  spontaneous  cure  were  reported  by  Pick  and  Schlagen- 
haufer,  the  former  describing  a  case  of  vaginal  metastasis  following  abortion. 
Schlagenhaufer  concluded,  from  the  observations  of  his  case,  that  there  are  two 
clinical  forms  of  the  disease.  The  first  is  extraordinarily  malignant  and  quickly 
overwhelms  the  organism  with  metastases,  while  the  second  form  is  benign  from 


372 


GYNECOLOGY 


the  outset.     He  further  stated  that  the  histologic  appearance  of  the  two  forms 
is  ahke. 

In  order  to  understand  the  microscopic  appearance  of  chorio-epitheHoma  it  is 
necessary  to  review  the  histology  of  the  chorionic  villus,  from  the  epithelial 
elements  of  which  the  chorio-epithehoma  has  its  origin.  The  chorionic  villus 
is  clothed  with  two  layers  of  epithelium,  the  outer  being  termed  the  "syncytium," 
and  the  inner  the  "layer  of  Langhans."     The  term  "syncytium,"  from  its  deriva- 


FiG.  122. — Placental  Polyp. 
Low  power.     The  light  areas  are  chorionic  villi,   cut  in  various  planes,  which  have  become 
hyaline  in  places  and  still  show  their  connective-tissue  structure  in  others.     They  have  lost  their 
epithelial  covering  of  Langhans'  cells  and  syncytium.     They  lie  in  fibrous  tissue  formed  by  the  organi- 
zation of  blood. 


tion,  denotes  a  fusing  together  of  cells,  and  describes  the  outer  layer,  in  that  it 
consists  of  a  continuous  mass  of  darkly  staining  protoplasm  in  which  are  more  or 
less  regularly  placed  nuclei.  There  are,  therefore,  no  definite  cell  boundaries. 
The  continuous  cell  mass  is  occasionally  interrupted  by  open  spaces  or  vacuoles. 
The  underlying  layer  (cells  of  Langhans)  is  composed  of  a  single  column  of  large 
bright  epithelial  cells  with  well-marked  boundaries  and  weakly  staining  nuclei. 
They  look  like  squamous  epithelium,  and  are,  in  fact,  derived  from  the  fetal 
ectoderm.     The  outer  layer  (syncytium)  is  derived  from  the  inner  layer  (Lang- 


NEW    GROWTHS 


373 


bans),  so  that  both  layers  are  fetal  in  origin.  Both  layers  in  the  normal  placenta 
have  a  tendency  to  proliferate  and  grow  outward  into  the  space  between  the 
chorionic  villi.  The  syncytial  covering  heaps  up  and  pushes  out  into  poty- 
poid  processes  that  may  become  broken  off.  Hence,  isolated  irregular  syncytial 
masses  may  often  be  found  in  the  intervillous  spaces.     In  this  way  syncytial 


1^/ 


r.-..^- 


J>*   'Sf' 


.^ 


-^ 


v'y,  ,  •? 


'V : , 


Fig.  123. — Placenta  at  Full  Term. 
Low  power.  On  the  right  is  an  area  of  decidua  consisting  of  greatly  enlarged  cells  derived  from 
the  stroma  of  the  endometrium.  The  enlargement  takes  place  mostly  in  the  protoplasm  of  the  cell, 
the  nucleus  enlarging  proportionately  little.  On  the  left  are  chorionic  villi  cut  in  various  planes. 
They  consist  of  a  loose  connective  tissue  containing  comparatively  large  blood-vessels,  covered  by  a 
layer  of  Langhans'  cells  and  syncytium.  The  intervillous  space  is  normally  filled  with  blood.  The 
small,  dark  areas  are  fragments  of  syncytium. 

elements  are  sometimes  taken  up  by  the  blood-current  and  transported  to  distant 
organs,  especially  the  lungs.  The  layer  of  Langhans  is  also  prone  to  proliferate, 
and  may  break  through  the  surrounding  syncytial  covering  and  grow  in  irregular 
masses  of  cells  that  include  fragments  of  the  syncytium  (see  Fig.  125).  The  pro- 
liferation of  these  two  epithelial  elements  may  be  considerable  and  yet  be  within 
physiologic  bounds. 


374  GYNECOLOGY 

In  chorio-epithelioma  exactly  the  same  overgrowth  takes  place  without 
change  in  the  appearance  of  the  cells,  excepting  that  it  progresses  to  a  malignant 
growth. 

When  the  fact  became  known  that  the  disease  might  be  either  benign  or 
malignant,  every  effort  was  made  by  pathologists  to  discover  some  distinguishing 
histologic  mark  by  which  the  two  forms  might  be  differentiated.  These  efforts 
have  been  unsuccessful.  Marchand,  Aschoff,  Zagorianski,  Kissel,  v.  Franque, 
Albrecht,  Hormann,  and  others  agree  that  we  have  absolutely  no  histologic 
criterion  for  determining  the  malignancy  of  these  tumors. 


Fig.  124. — Hydatid  Mole. 
Low  power.  Parts  of  two  chorionic  villi  are  seen  running  across  the  field.  They  are  tremen- 
dously swollen,  as  may  be  seen  if  this  is  compared  with  the  drawing  of  the  placenta  at  full  term.  The 
layer  of  Langhans'  cells  covered  with  syncytium  are  well  shown  on  the  surface  of  the  villi.  On  the 
space  between  the  villi  in  the  center  are  several  fragments  of  syncytium.  This  space  is  normally  filled 
with  blood  in  which  these  fragments  lie. 

Moreover,  a  further  difficulty  in  diagnosis  exists  in  the  fact  that  the  tumors 
exactly  resemble  the  normal  fetal  tissue. 

Hitschmann  and  Cristofoletti  came  to  the  following  conclusion: 

"As  a  matter  of  fact,  we  are  convinced  that  a  histologic  difference  is  entirely 

improbable.     We  know  of  absolutely  no  morphologic  and  biologic  difference 

between  the  physiologic  fetal  tissue  and  the  pathologic.     The  more  carefully  we 

study  the  earliest  phases  of  placenta  formation  and  compare  them  with  chorio- 


NEW    GROWTHS 


375 


epithelioma,  the  more  we  feel  justified  in  the  statement  that  between  trophohlast 
(fetal  tissue)  and  chorio-e'pithelioma  there  is  no  difference." 


;tPW, 


Fig.  125. — Chorionic  Villus,  Showing  Growth  of  Langhans'  Cells  Breaking  Through  the 
Syncytium  into  the  Intervillous  Space. 
Fragments  of  syncytium  are  seen  in  the  sprouting  mass  of  Langhans'  cells.     On  the  right  is 
a  collection  of  Langhans'  cells,  more  highly  magnified,  surrounding  syncytial  fragments.      (After 

Winter.) 


The  same  writers  call  attention  to  the  biologic  resemblance  that  exists  between  the  tropho-~ 
blast,  or  fetal  tissue,  and  chorio-epithelioma.  "All  the  characteristics  of  the  tumor  cells  are 
to  be  found  in  the  normally  functioning  trophoblast.     The  enormous  capacity  for  growth  of  the 


Fig.  126. ^Syncytium  and  Langhans'  Cells.  ' 

Two  chorionic  villi  are  seen,  showing  the  outer  syncytial  envelope  and  the  inner  layer  of  Lang- 
hans' cells.  In  the  center  is  a  mass  of  proliferating  Langhan's  cells  in  which  are  scattered  fragments  of 
syncytium.      (After  Winter.) 


fetal  ceUs,  the  destruction  of  maternal  blood-vessels  are  apparent  in  both,  excepting  that  in  the 
physiologic  tissue  there  is  a,  local  and  time  hmitation.  The  relation  of  the  fetal  cells  to  the 
maternal  tissue  is  just  the  same.     The  tnost  important  function  of  the  trophoblast  is  the  destructio7i 


376 


GYNECOLOGY 


of  the  maternal  tissue,  especially  the  erosion  of  the  blood-vessels.  In  this  way  does  the  young  egg 
come  into  relationship  with  the  mother's  blood,  the  intervillous  circulation  become  established, . 
and  the  nourishment  of  the  egg  remain  assured.  The  entire  egg  rests  within  the  maternal  blood- 
vessels and  is  bathed  in  maternal  blood. 

"These  same  .characteristics  v/e  find  in  the  chorio-epithelioma.  There  is  the  same  destruc- 
tive faculty,  the  same  elective  behavior  toward  the  maternal  blood,  and,  therefore,  the  almost 
exclusive  extension  by  way  "of  the  blood-stream.  Both  tissues  have  no  supporting  tissue  struc- 
ture, no  individual  blood-vessels,  and  both  are  dependent  for  their  nourishment  on  the  circulat- 
ing blood  of  the  mother.     The  fetal  cells  of  the  trophoblast  are,  therefore,  morphologically  and 


°f«^' " ." 


X.'--^' 


Fig.  127. — Syncytium  in  the  Decidua. 
Low  power.     This  illustrates  the  wandering  of  fragments  of  syncytium  in  the  decidua.     The 
dark  masses  consist  of  syncytium  which  were  found  in  the  decidua.    Several  glands  are  seen,  as  this 
is  endometrium. 

biologically  identical  with  the  cells  of  the  malignant  chorio-epithelioma.  Therefore,  in  diag- 
nosing a  chorio-epithelioma  no  safe  conclusion  may  be  drawn  from  the  destruction  of  the  mater- 
nal tissue  as  to  its  malignancy,  because  destruction  of  the  maternal  tissue  is  the  most  important 
function  of  the  trophoblast."     (Translation.) 

Symptoms. — Chorio-epithelioma  usually  makes  itself  known  by  repeated 
uterine  hemorrhages  following  an  abortion  or  a  mole.  Bleeding  is  always  the 
characteristic  symptom,  no  matter  where  the  tumor  is  located,  and  is  due  to  the 
corrosive  action  of  the  tissue  on  the  walls  of  blood-vessels  with  which  it  comes 


NEW    GROWTHS 


377 


in  contact.  Cureting  brings  about  only  a  temporary  cessation  of  the  bleeding, 
which  is  apt  to  be  severe  and  depleting.  The  patient  becomes  rapidly  anemic 
and  cachectic.  Albuminuria  is  a  very  frequent  accompaniment.  A  second 
cureting  reveals  a  new  mass  of  tissue  in  the  canal  of  the  uterus.  A  diagnosis  by 
microscopic  examination  of  the  curetings  is  very  difhcult  to  make,  as  is  explained 
above,  and  patients  are  often  lost  as  a  result  of  a  negative  report  from  the 
pathologist.     It  is  extremely  necessary,  therefore,  to  take  into  account  the  clin- 


Fig.  128. — Chorio-epithelioma. 
Low  power.     At  the  bottom  is  the  edge  of  a  chorionic  villus  covered  with  a  regular  layer  of  Lang- 
hans'  cells.    In  the  middle,  lying  on  this,  is  syncytium.    To  the  left  of  this  and  above  it  are  masses  of 
Langhans'  cells.     Near  the  top  and  near  the  right  edge  are  large  fragments  of  syncytium  haA-ing  the 
larger,  deeper  staining  nuclei  and  deeper  staining  protoplasm,  the  whole  floating  in  blood. 


ical  course  of  the  disease,  without  relying  too  much  on  the  findings  of  the  micro- 
scope. After  metastases  occur  the  diagnosis  is  simple,  but  it  is  then  usually  too 
late  for  treatment,  though  cases  of  spontaneous  cure  even  at  this  stage  have  been 
reported. 

Metastases  frequently  occur  in  the  vagina,  and  sometimes  the  first  evidence 
qf  the  disease  is  seen  here,  the  chief  symptom  being  bleeding.  On  account  of  the 
corrosive  action  of  the  tumor  and  the  friability  of  its  tissue,  metastatic  emboli 


378 


GYNECOLOGY 


slip  very  readily  into  the  blood-stream  and  are  carried  to  distant  parts  of  the 
body.  The  embolic  masses  when  lodged  grow  and  corrode  the  neighboring 
blood-vessels,  causing  local  hemorrhages.  Sometimes  symptoms  from  the 
metastatic  growths  give  the  first  warning  of  the  disease  without  uterine  mani- 
festations. Metastases  to  the  lungs  are  especially  common,  and  cause  pulmonary 
hemorrhages,  or  they  may  be  localized  in  the  brain,  liver,  or  kidneys,  etc. 

In  making  a  diagnosis  of  chorio-epithelioma,  and  coming  to  a  decision  as  to 
the  treatment,  the  surgeon  often  find&  himself  in  a  serious  predicament.  The 
situation  which  presents  itself  in  a  suspected  case  is  somewhat  as  follows: 


Fig.  129. — Chorio-epithelioma. 
High  power.     This  tissue  consists  of  Langhans'  cells.     The  nuclei  and  cell  protoplasm  do  not 
stain  as  deeply  as  they  do  in  syncytium,  the  nuclei  are  not  as  large,  and  the  cell  boundaries  can  be 
seen.     No  cell  walls  are  found  in  syncytium,  it  being  held  together  by  fine  protoplasmic  threads. 

A  patient,  some  time  after  deliverj^  of  a  hydatidif orm  mole  or  after  an  abortion, 
begins  to  bleed  profusely.  A  cureting  is  done,  and  a  considerable  amount  of 
tissue  is  removed  from  the  uterine  canal,  which,  on  microscopic  examination, 
shows  numerous  fetal  elements.  Many  Langhans'  cells  are  seen  in  groups, 
and  in  different  places  may  be  seen  great  syncytial  masses  with  large,  variously 
formed  protoplasm.  Such  a  picture  may  correspond  either  to  a  placental  rest 
or  to  a  benign  form  of  chorio-epitheUoma,  or  to  an  early  stage  of  a  malignant 
chorio-epithehoma.     If  radical  operation  is  done  there  is  a  chance  that  the 


NEW    GROWTHS 


379 


patient  will  be  subjected  to  needless  danger,  with  the  loss  of  her  pelvic  organs, 
for  there  is  no  wa.y  of  telling  that  the  condition  in  the  uterus  is  not  perfectly 
harmless.  If  one  does  not  operate,  and  waits  for  later  symptoms  to  develop, 
metastases  may  take  place  and  it  will  be  too  late  to  save  the  patient.  More- 
over, one  is  confronted  by  the  fact  that  a  curetment  sometimes  turns  a  benign 
form  of*  the  disease  into  immediate  and  overwhelming  malignancy,  as  is  em- 
phatically pointed  out  by  Hitschmann  and  Cristofoletti.  Cases  have  been 
reported  where  the  initial  curetings  have  been  examined  and  pronounced  by 
competent  pathologists  as  malignant,  and  the  extirpated  uteri  have  later  been 


Fig.  130. — Chorio-epithelioma. 
High  power.     Most  of  the  tissue  consists  of  Langhans'  cells  the  nuclei  of  which  do  not  stain  as 
deeply  as  those  of  the  syncytium,  and  the  cell  outlines  of  which  can  usually  be  seen.     Near  the  center 
are  two  syncytial  nuclei  which  are  larger,  irregular  in  shape,  and  stain  deeply.     Near  the  right 
upper  edge  is  a  mitotic  figure  in  a  syncytial  nucleus. 


found  to  be  perfectly  normal.  Whichever  course  the  surgeon  adopts,  he  is 
running  a  risk,  and  he  must  depend  to  a  certain  extent  on  his  surgical  instinct 
to  make  the  right  decision. 

If  the  initial  curetings  show  large  or  overwhelming  numbers  of  grouped 
Langhans'  and  syncytial  cells,  immediate  radical  operation  is  advisable,  especi- 
ally if  a  hydatidiform  mole  has  preceded.  If  the  initial  curetings  show  con- 
spicuous, though  not  numerous,  characteristic  cell  collections,  the  case  is  re- 
garded with  grave  suspicion,  and,  if  the  symptoms  have  been  preceded  by  a 
mole,  radical  operation  is  seriously  considered.     If,  however,  the  symptoms 


380 


GYNECOLOGY 


have  followed  abortion,  it  is  justifiable  to  wait  to  see  if  further  bleeding  ensues, 
which,  according  to  Meyer,  will  usually  take  place  in  two  or  three  weeks  if  the 
disease  recurs,  though  the  patient  should  be  kept  under  strict  observation  for 
several  months,  even  if  her  catamenia  is  normal. 

If  after  the  careful  cureting  of  a  suspicious  case,  bleeding  recurs,  and  the 
curetings  again  show  the  same  findings,  radical  operation  is  indicated. 

The  surprising  way  in  which  some  seeminglj-  very  malignant  chorio-epi- 
theliomata    heal    spontaneously,    even    after    incomplete   operations,  is  inter- 


FiG.  131. — Chobio-epithelioma. 
High  power.     At  the  bottom  is  the  edge  of  a  chorionic  villus.     The  first  layer  of  cells  covering  it 
consists  of  Langhans'  cells.     Covering  this  is  syncytiiim  and  throughout  the  rest  of  the  drawing  are 
masses  of  syncytium  lying  in  coagulated  blood.     In  the  lower  center  is  seen  the  vacuolated  appear- 
ance which  syncytium  has. 


estingly  explained  by  Hitschmann  and  Cristofoletti.  These  writers  observed 
in  their  own  and  reported  cases  the  very  common  occurrence  of  parametrial 
infiltration.  From  the  study  of  autopsies  and  surgical  cases  they  found  that 
this  infiltration  does  not  consist  in  an  invasion  of  the  parametrial  connective 
tissue  by  the  cancerous  elements,  but  that  the  thickening  is  due  to  a  thrombosis 
of  the  parametrial  and  spermatic  veins. 

This  thrombosis  of  the  large  pelvic  veins  may  act  in  two  ways :  either  it  may 
become  a  new  focus  for  metastasis  and  send  off  embohc  mahgnant  masses  to 


NEW    GROWTHS  381 

the  lungs,  where  they  may  erode  the  puhiionary  arteries  and  spread  rapidly 
over  the  whole  body,  or  the  thrombosis,  by  interfering  with  the  uterine  circula- 
tion, may  cause  a  necrosis  of  the  tumor  cells,  which  are  very  dependent  for  hfe 
on  the  maternal  blood-stream,  and  by  this  necrosis  cause  a  further  thrombosis 
of  the  veins.  In  this  way  the  thrombosis  may  become  a  protective  barrier  to 
metastases,  and  serve,  at  the  same  time,  to  produce  disintegration  and  death 
of  the  entire  growth.  The  writers  present  cases  which  convincingly  substantiate 
this  theory. 

If  the  idea  is  correct,  it  is  of  very  great  practical  value.  It  shows  that  the 
route  of  metastasis  is  through  the  pelvic  veins,  so  that  great  care  must  be  exer- 
cised in  cureting  or  operating  on  these  cases  to  avoid  sending  emboli  artificially 
into  the  circulation  by  insulting  the  diseased  tissue,  which,  being  without 
supporting  structure,  is  extremely  friable  and  susceptible  to  embolism.  For 
this  reason  it  is  inadvisable  to  perform  the  radical  operation  by  the  vaginal 
route.  When  the  operation  is  done  abdominally  the  first  step  must  be  to  tie 
the  hypogastric  and  spermatic  veins  in  order  to  block  the  avenues  for  emboli. 
If  the  case  is  inoperable  as  far  as  the  uterus  and  parametrium  are  concerned, 
the  large  veins  should  be  tied,  in  the  hope  of  interfering  with  the  circulation  of 
the  tumor  and  preventing  metastasis. 

If  the  case  is  operable  a  total  extirpation  should  be  performed  by  the  Wert- 
heim  method. 

TUMORS   OF  THE   OVARY 

No  organ  of  the  body  has  so  great  a  disposition  to  tumor,  especially  cyst 
formation,  as  has  the  ovary,  as  would  be  expected  from  the  natural  charac- 
teristics of  its  tissues.  The  enormous  proliferating  power  of  germinal  epi- 
thelium, the  physiologic  process  of  atresia  and  cyst  formation,  the  monthly 
congestion,  and  the  secretory  power  of  the  epithelial  structures  are  all  normal 
forces  which  it  may  well  be  imagined  are  readily  transformed  from  physiologic 
functions  to  pathologic  processes. 

Tumors  of  the  ovary  are  divided  into  two  main  groups — (1)  non-proliferating 
tumors  and  (2)  proliferating  tumors. 

(1)  Non-proliferating   Tumors 

The  tumors  of  this  group  represent  errors  in  the  development  and  regres- 
sion of  the  Graafian  follicles  which  result  in  retention  cysts.  These  cysts  are  of 
two  kinds — those  which  are  produced  by  abnormal  secretion  of  an  atretic  follicle, 
follicle  cysts,  and  those  which  are  consequent  on  incomplete  involution  of  a 
corpus  luteum. 

Follicle  Cysts. — We  have  seen  in  the  section  on  Physiology  that  only  a  com- 
paratively few  of  the  primary  folhcles  with  which  the  ovary  is  originally  endowed 


382 


GYNECOLOGY 


come  to  full  maturity.     Most  of  the  follicles  during  some  stage  of  their  develop- 
ment become  aborted;  the  ovulum  dies;  the  epithelium  of  the  membranosa 


Fig.  132. — Cystic  Degeneration  of  the  Ovary. 
Macroscopic  drawing  of  a  section  of  a  whole  ovary.     In  the  cortex  are  several  small  cysts  which 
microscopically  proved  to  be  cysts  of  Graafian  follicles.     On  the  left  are  cysts  with  only  thin  parti- 
tions between  them,  suggesting  how,  as  they  become  larger,  the  partition  thins  out,  ruptures,  and 
allows  two  cysts  to  coalesce  into  one. 


MMo»TCT<< 


Fig.  133. — Cyst  of  a  Graafian  Follicle. 
Low  power.  At  the  top  is  the  lining  of  the  cyst  consisting  of  one  to  several  layers  of  cells  derived 
from  the  membrana  granulosa  of  the  follicle.  This  lies  on  the  connective-tissue  stroma  of  the  ovary. 
Through  the  center  of  the  section  are  several  Graafian  follicles,  the  cells  of  which  have  fallen  out  in 
cutting  the  section.  The  lower  part  of  the  section  is  the  cortex  of  the  ovary,  the  epithelial  covering 
being  absent. 


degenerates  and  disappears.  This  process  is  termed  atresia  oj"  the  follicle,  and 
is,  in  a  certain  sense,  physiologic.  Atresia  of  a  follicle  is  attended  with  a  certain 
amount  of  secretion,  especially  when  the  lining  epithelium  (granulosa)  persists, 


NEW    GROWTHS 


383 


SO  that  many  of  the  folhcles  become  visible  cysts  of  greater  or  less  dimensions. 
This  cyst  formation  is,  within  certain  limits,  to  be  regarded  as  a  physiologic 
process.  Under  certain  conditions,  however,  the  production  of  these  cysts 
becomes  abnormally  great,  and  the  ovary  is  then  said  to  be  in  a  state  of  cystic 
degeneration,  though  the  line  between  the.  normal  and  abnormal  state  is  not 
clearly  defined.  Just  what  causes  cystic  degeneration  is  a  matter  of  some 
doubt.  Increased  density  of  the  connective-tissue  stroma  (interstitial  oophori- 
tis), which  prevents  proper  resorption  of  the  atretic  follicle  elements,  probably 


Fig.  134. — Cyst  of  a  Graafian  Follicle. 
High  power.     At  the  top  is  the  lining  of  the  cyst  wall,  consisting  of  layers  of  cells  derived  from 
the  membrana  granulosa  of  the  follicle.     Below  this  is  the  loose  connective  tissue  that  surrounds  the 
follicle,  and  below  this  the  dense  connective  tissue  of  the  cortex  of  the  ovary. 


acts  as  a  cause  in  a  certain  number  of  cases.  In  other  instances  it  is  likely  that 
disturbances  of  circulation,  such  as  repeated  or  continuous  hyperemia,  may 
cause  a  too  rapid  development  of  the  primordial  follicles  and  hence  an  over- 
production of  atretic  follicles. 

Cystic  degeneration  causes  a  general  enlargement  of  the  ovary,  but  it  does 
not  reach  the  dignity  of  a  tumor  until  one  of  the  cysts  grows  at  the  expense 
of  tlie  other  cysts  and  the  rest  of  the  ovarian  tissue. 

The  growth  of  an  atretic  follicle  cyst  may  be  due  to  persistence  of  the  lining 


384 


GYNECOLOGY 


epithelium  which  continues  to  secrete  a  clear  amber  fluid  (v.  Franque).  Usually, 
however,  the  membrana  granulosa  disintegrates  and  disappears.  The  growth 
of  the  cyst  is  then  conditioned  on  a  transudation  from  the  blood-vessels  of  the 
theca  interna,  which  may  persist  for  a  long  time. 

As  a  rule,  only  one  cyst  takes  on  this  abnormal  growth,  though  sometimes 
there  may  be  two  and  even  three.  As  the  cyst  continues  slowly  to  enlarge,  the 
rest  of  the  ovarian  tissue,  including  the  other  folhcle  cysts,  becomes  compressed, 
so  that  finally  it  becomes  stretched  out  and  incorporated  in  the  thin  wall  of  the 
usurping  cyst,  appearing  only  as  a  whitish,  opaque  thickening  of  the  wall. 


Fig.  135. — Corpus  Luteum  Cyst  of  Ovary. 
Macroscopic  drawing,  enlarged,  of  section  of  whole  ovary.  On  the  right  is  a  corpus  luteum  show- 
ing well  the  plicated  envelope  of  lutein  cells.  The  cavity  was  filled  with  cloudy  fluid,  as  in  this  case 
the  blood  did  not  organize  and  we  have  an  early  stage  of  corpus  luteum  cyst.  On  the  left  are  several 
corpora  lutea  which  have  gone  on  to  the  stage  of  corpus  albicans,  and  at  the  top  one  small  corpus 
luteum  still  in  process  of  organization. 


The  great  majority  of  folHcle  retention  cysts  reach  a  fairly  uniform  size, 
about  that  of  the  fist.  They  have  a  thin  translucent  wall,  usually  with  no  sign 
of  epithelial  hning.     Most  of  them  are  monolocular. 

Some  of  the  folhcle  cysts  grow  to  a  much  larger  size,  even  to  that  of  a  man's 
head.  The  larger  cysts  are  lined  with  epithehum,  and  the  greater  size  of  the 
cyst  is  due  to  active  secretion  on  the  part  of  the  Hning  epithelium.  Follicle 
cysts  of  this  type  cannot,  therefore,  be  regarded  properly  as  retention  cysts. 
There  is  also  a  question  whether  they  should  be  included  as  non-proliferating 


NEW    GROWTHS 


385 


tumors.  Von  Franque  does  not  consider  the  persistence  and  increase  of  the 
epithehal  Uning  structure  sufficient  cause  to  include  them  in  the  new-growth 
tumors,  and  points  to  a  similar  growth  of  tubal  epithelium  in  the  large  hydro- 
salpinges. 

Follicle  cysts  are  essentially  benign  and  have  almost  no  tendency  to  papil- 
lary outgrowth.      Occasionally  wart-like  excrescences  are  found  on  the  inner 


''S, 


i'' 


/>'^'  °-  ->  '^  >■'   ^''  .°'  ^^,  ^^ 


Fig.  136. — Corpus  Luteum  Cyst. 
Low  power.     The  space  in  the  center  is  the  cavity  of  the  cyst.     Lining  it  is  a  thin  layer  of  con- 
nective tissue  which  lies  on  a  layer  of  dense  fibrous  tissue  which  formally  was  made  up  of  lutein  cells, 
the  whole  being  surrounded  by  vascular  connective  tissue,  in  which  is  a  slight  infiltration  of  round 
cells. 

surface,  but  these,  as  a  rule,  represent  only  local  hyperplasia  of  the  connective 
tissue  rather  than  an  overgrowth  of  epithelium. 

Corpus  luteum  cysts  differ  from  folhcle  cysts  in  that  they  represent  a  cystic 
formation  that  takes  place  in  a  more  advanced  stage  of  development  of  the 
folhcle.  They  attain  about  the  same  dimensions  as  the  follicle  cysts.  They  are 
recognizable  in  the  earher  stages  by  the  wavy,  characteristically  yellow  lutein- 
cell  lining.  The  cyst  content  is  usually  of  a  reddish,  turbid  character,  in  dis- 
tinction from  the  clear  amber  fluid  of  the  folhcle  cysts.     In  the  large  corpus 

25 


386 


GYNECOLOGY 


luteum  cysts  epithelial  elements  may  be  entirely  wanting,  so  that  they  cannot 
be  identified  from  follicle  cysts  even  by  microscopic  examination. 

Blood-cysts  of  the  ovary  may  result  from  the  internal  bleeding  of  follicle 
or  corpus  luteum  cysts.  According  to  von  Franque,  hemorrhages  may  occur 
in  the  ovarian  stroma  in  cases  of  chronic  oophoritis  which  causes  a  special 
frangibility  of  the  blood-vessels.  Such  hemorrhages  take  place  at  the  men- 
strual periods,  and  repeated  hemorrhages  at  consecutive  menstruations  may  cause 


Fig.  137. — Corpus  Luteum  Cyst. 
High  power.     To  the  right  is  the  cavity  of  the  cyst.     Lining  this  is  seen  a  thin  layer  of  con- 
nective tissue.     A  line  of  demarcation  can  be  seen  between  this  layer  and  the  next  which  consists 
of  fibrous  tissue  rather  more  dense,  which  has  taken  the  place  of  the  layers  of  lutein  cells.     On  the  left 
is  the  connective-tissue  stroma  of  the  ovary  with  a  few  round  cells  in  it. 

blood-cysts  of  considerable  size.  The  fresh  outflow  of  blood  may  produce  severe 
pain  and  serious  symptoms,  even  death.  As  a  rule,  however,  the  condition  is 
not  a  serious  one,  and  the  discharged  blood  is  gradually  resorbed.  Doubtless 
some  of  the  puzzling  cases  in  which  an  ovarian  cyst  is  unmistakably  felt  by 
vaginal  examination,  only  to  disappear  completely  in  a  comparatively  short 
time,  are  instances  of  blood-cysts.  True  cysts,  unless  they  rupture,  do  not 
disappear  in  this  way.     To  the  non-proliferating  cysts  of  the  ovary  is  given  the 


NEW    GROWTHS  387 

name  cystoma,  or  cj^stoma  simplex.  This  term  implies  a  simple  cystic  enlarge- 
ment of  the  ovary,  and  must  be  distinguished  from  the  word  ajstadenojjia, 
which  is  applied  to  the  true  proliferating  cysts. 

In  addition  to  the  corpus  luteum  cysts  are  other  cysts,  called  theca-lutein 
cysts.  The  theca-lutein  cysts  develop  from  atretic  follicles,  but  the  cells  of 
the  theca  interna  (connective  tissue)  become  hypertrophied  and  form  a  layer 
on  the  inside  of  the  follicle  which  looks  much  like  the  lutein  layer  of  the  true 
corpus  luteum  The  layer,  however,  is  not  as  wavy  and  folded,  nor  are  the 
cells  as  large  and  well  marked,  as  the  true  lutein  cells.  To  distinguish  them 
they  are  called  theca-lutein  cells.  Isolated  remnants  of  these  theca-lutein  cells 
found  in  the  ovaries  constitute  the  so-called  interstitial  gland,  which  it  is 
thought  may  play  some  part  in  the  production  of  the  ovarian  internal  secretion. 

It  is  not  always  possible  to  distinguish  between  a  corpus  luteum  cyst  and  a 
theca-lutein  cyst  unless  the  yellow  layer  hning  the  cyst  is  markedly  folded 
and  the  cells  large  and  unmistakable.  The  theca-lutein  cysts  may  contain 
hematomata,  and  thc}^  may  become  infected  from  the  tube  in  the  same  ways 
as  the  corpus  luteum  cysts. 

The  theca-lutein  cysts  are  especially  in  evidence  in  association  with  hydatid 
mole  or  a  chorio-epithelioma.  It  is  estimated  that  in  more  than  50  per  cent. 
of  cases  of  mole  the  ovary  undergoes  a  cystic  degeneration,  which  disappears 
after  the  removal  of  the  mole.  These  cystic  ovaries  have  been  shown  to  con- 
tain theca-lutein  cysts.  They  are  about  the  size  of  an  apple  and  usually  multiple. 
They  are  hned  with  a  lutein  layer,  which,  however,  is  flatter  and  thinner  than 
that  of  a  true  corpus  luteum.  They  do  not  have  much  clinical  significance,  as 
they  usually  regress  if  the  patient  does  not  die  from  the  disease  of  the  placenta. 

There  has  been  some  debate  as  to  whether  the  cystic  condition  of  the  ovary 
is  the  result  or  the  cause  of  the  degenerative  processes  of  the  chorion  seen  in 
hydatid  mole  and  chorio-epithelioma.  It  seems  likely  that  the  cysts  represent 
an  excess  in  the  process  of  atresia  of  the  follicles  that  normally  takes  place 
during  pregnancy. 

It  is  important  to  bear  in  mind  the  possibihty  of  the  occurrence  of  these 
cysts  with  mole  or  chorio-epithelioma,  for  otherwise  their  discovery  might  lead 
to  the  diagnosis  of  metastases  from  the  original  disease. 

(2)  Proliferating   Tumors   of  the   Ovary 

The  proliferating  tumors  represent  neoplastic  growths  from  the  ovarian 
tissue,  and  are  divided  into  two  classes,  according  to  whether  they  develop 
from  the  epithelial  (parenchymatous)  elements  or  whether  they  arise  from  the 
connective-tissue  (stromatogenous)  structure. 

Parench3rmatous  Tumors. — About  80  per  cent,  of  all  new  growths  of  the 
ovary  have  a  glandular  or  adenomatous  character,  of  which  b}^  far  the  greater 
number  exhibit  secretory  activity  on  the  part  of  the  epithelial  cells  that  line  the 
glandular  structures.     The  term  cystadenoma  is,  therefore,  given  to  these  tumors 


388 


GYNECOLOGY 


to  indicate  the  pathologic  process  that  underlies  their  growth.  The  glandular 
proliferation  takes  place  from  the  epithelial  cells  that  line  the  original  cyst,  and 
is  represented  by  the  formation  of  daughter  cysts,  which  in  turn  reproduce 
themselves  in  the  same  waj^  until  innumerable  cysts  are  formed.  In  this  waj^ 
the  main  tumor  is  made  up  of  many  cystic  chambers,  and  is,  therefore,  called 
multilocular.     All  cystadenomata  are  essentially  multilocular. 


Fig.  138. — Pseudomucinous  Ctstadenoma  of  the  Ovary. 
High  power.     This  drawing  shows  the  glands  characteristic  of  this  tumor.     They  are  lined  by  a 
single  layer  of  high  cells  having  small  nuclei  lying  at  the  bases  of  the  cells.     The  glands  lie  in  connec- 
tive tissue  derived  from  the  stroma  of  the  ovary. 


It  may,  however,  happen  that  one  or  a  few  cysts  grow  at  the  expense  of  the 
others  which  become  compressed  into  the  surrounding  wall,  or  many  small 
cysts  may  rupture  and  become  confluent  into  one  larger  cyst,  so  that  the  tumor 
may  have  the  appearance  of  a  single  cyst  (monolocular)  or  there  may  be  only 
a  few  chambers  apparent  (parvilocular) .  Microscopic  examination  of  the  walls 
of  such  tumors  reveals  their  true  multilocular  nature.  The  epithelium  of  cyst 
adenomata,  in  addition  to  its  power  of  producing  daughter  cysts,  is  prone  to 


NEW    GROWTHS 


389 


sprout  forth  into  papillary  branches.  This  usually  takes  place  toward  the 
lumen  of  the  cyst,  in  which  case  the  growth  is  said  to  be  ''inverting."  The 
papillae  may  also  grow  outwardly  and  appear  as  excrescences  on  the  outer  sur- 
face of  the  main  tumor,  in  which  case  they  are  termed  "everting."  The  epi- 
thehurn  from  these  tmnors,  when  broken  off  from  the  papillary  excrescences  of 
the  outer  wall,  or  when  it  escapes  from  the  cyst  lumen  through  a  rupture  of  the 
wall,  has  the  power  of  becoming  implanted  in  the  tissue  on  which  it  falls  and  of 
reproducing  both  the  glandular  cystic  and  the  papillary  processes  that  it  -de- 


FiG.  139. — Pseudomucinous  Cystadenoma  of  the  Ovary. 
Low  power.     The  lining  epithelium  of  the  cyst  cavity  is  seen  at  the  top  and  consists  of  a  single 
layer  of  cylindric  epithelium  having  small  nuclei  that  lie  at  the  bases  of  the  cells.     These  cells  have 
the  power  of  secreting  pseudomucin  in  large  amounts. 

velops  in  the  main  tumor.  These  extraneous  growths  are  called  seed  or  implan- 
tation metastases.  They  are  most  commonly  seen  on  the  peritoneum  of  the 
abdominal  viscera  and  parietes. 

The  cystadenomata  of  the  ovary  are  of  two  types  which  differ  markedly 
from  each  other  in  their  contents,  histologic  structure,  and  tendency  to  papillary 
and  malignant  proliferation.  They  are  named,  from  the  character  of  their 
contents,  ''cystadenoma  pseudomucinosum"  and  "cystadenoma  serosum." 

The  -pseudomucinous  cystadenomata  are  said  to  constitute  the  commonest  form 


390 


GYNECOLOGY 


of  ovarian  tumors,  though  in  our  own  series  of  cases  they  have  been  found  less 
frequently  than  have  the  serous  cystadenomata.  They  are  usually  unilateral, 
and  rarely  develop-  between  the  leaves  of  the  broad  ligament,  tending  rather  to 
have  well-formed  pedicles.  These  cysts  are  oval  in  shape,  with  a  smooth  sur- 
face. They  are  always  multilocular,  and  are  distinctly  glandular  in  tjrpe. 
The  single  chambers  of  the  tumor  vary  greatly  in  size,  usually  a  few  of  them 
growing  to  considerable  proportions  at  the  expense  of  the  others.  The  fluid 
contents  consist  of  a  thick  mucoid  substance,  which  resembles  closely  true 


Fig.  140.  — Pseudomucinous  Cystadenoma  of  the  Ovaby. 
High  power.     From  the  specimen  seen  in  Fig.  139. 

mucus  in  appearance,  but  differs  from  it  in  that  it  does  not  present  the  char- 
acteristic mucin  reaction  with  acetic  acid;  hence  its  name,  "pseudomucin." 

The  color  of  the  pseudomucin,  which  in  its  pure  state  is  of  a  clear  glassy 
transparency,  may  be  considerably  altered  by  transudations  from  the  blood- 
vessels and  by  necrotic  changes  in  the  cyst  wall,  from  torsion,  so  that  it  may 
present  numerous  tints,  from  yellowish  or  greenish-gray  tones  to  dirty  brown 
or  even  black.  Often  a  characteristic  greenish,  shimmering  hue  is  seen,  due  to 
the  presence  of  cholesterin  plates,  which  represent  a  product  of  regressive 
changes  in  the  cellular  elements  (von  Franque).     The  reaction  is  alkahne. 


NEW    GROWTHS 


391 


The  cysts  are  lined  with  a  high,  non-cihated,  cyhndric  epithelium  with  a 
basal  nucleus.  During  activity  these  epithelial  cells  assume  the  characteristic 
appearance  of  beaker  cells,  and  secrete  pseudomucin  in  the  same  way  as  the 
lining  cells  of  the  stomach  or  gall-bladder  secrete  true  mucus.  The  cells  are 
beautifully  arranged  in  regular  order  in  a  single  layer.  As  distinguished  from 
the  serous  cystadenomata,  papillary  outgrowth  of  the  Hning  epithelium  is 
comparatively  rare. 

From  a  clinical  standpoint,  the  pseudomucinous  cysts  belong  to  the  class 
of  benign  neoplasms.  They  grow  very  slowly  and  may  reach  enormous  dimen- 
sions. The  famous  classical  ovarian  tumors  of  great  size  that  were  frequently 
described  before  the  days  of  modern  surgery  were  of  this  type.     They  rarely 


Fig.  141. — Contour  of  Abdomen  Containing  a  Large  Ovarian  Cyst. 
(Reproduced  from  a  photograph.) 

develop  carcinomatous  degeneration,  in  which  they  are  again  distinguished  from 
the  serous  variety,  which  has  an  especial  tendency  to  malignanc3^ 

From  an  operative  standpoint,  the  pseudomucinous  cysts  are  particularly 
favorable.  The  operation  itself  is  usually  attended  with  little  difficulty,  be- 
cause, having  no  inclination  to  grow  between  the  leaves  of  the  broad  ligament, 
they  usually  lie  free  in  the  abdomen,  with  an  easily  accessible  pedicle.  Adhe- 
sions to  the  intestines  are  not  present  unless  the  tumor  is  complicated  by  some 
inflammatory  process,  such  as  might  ensue  from  salpingitis  or  from  torsion  of 
the  pedicle.  Inasmuch  as  the  disease  is  usually  confined  to  one  side,  and  as 
there  is  little  tendency  to  later  recurrence  in  the  unaffected  ovary,  a  simple 
extirpation  of  the  tumor,  without  removal  of  the  other  organs  of  the  pelvis,  is 
all  that  is  necessarv.     It  should  be  remembered,  however,  that  carcinomatous 


392 


GYNECOLOGY 


degeneration,  though  rare,  is  still  possible,  and  the  rule  of  making  a  careful 
gross  examination  of  the  growth  before  closing  the  abdomen  should  always  be 
carried  out,  as  in  the  removal  of  all  ovarian  neoplasms.  If  carcinoma  is  discov- 
ered, the  uterus  and  other  ovary  should  be  removed.  According  to  Pfannenstiel, 
carcinomatous  recurrences  have  taken  place  in  the  scar  of  the  stump  from  which 
the  tumor  has  been  removed.  This  complication,  however,  must  be  so  rare  that 
it  need  not  be  taken  into  very  serious  consideration. 


Fig.  142. — Papillary  Cystadenoma  of  the  Ovary. 
Low  power.     The  papillary  projections  from  the  wall  of  the  cyst  can  be  seen  cut  in  various 
planes.     They  consist  of  a  connective-tissue  stroma  containing  blood-vessels,  covered  with  a  single 
layer  of  cylindric  epithelium. 


The  spilling  of  the  cyst  contents  in  the  abdominal  cavity  is  attended  with 
less  risk  than  in  the  case  of  serous  cystadenomata,  as  the  epithelial  elements 
have  less  tendency  to  implant  themselves  on  the  peritoneum.  This,  however, 
is  not  universally  true,  for  it  occasionally  happens  that  cell  elements  that  have 
escaped  from  the  cyst  into  the  peritoneal  cavity,  either  spontaneously  or  from 
accidental  rupture  during  operation,  form  implantation  metastases,  which,  by 
the  peristaltic  movements  of  the  intestine,  may  become  disseminated  through- 
out the  abdomen.      The  cells  continue  to  secrete  pseudomucin,  so  that  as  a 


NEW    GROWTHS 


393 


result  the  entire  peritoneal  cavity  becomes  filled  with  extensive  gelatinous 
masses  that  cannot  easily  be  removed.  This  condition  has  been  described  by 
Werth,  and  named  by  him  pseudomyxoma  peritonei.  The  process,  though 
essentially  benign,  has,  nevertheless,  a  bad  prognosis,  for  the  gelatinous  masses, 
acting  on  the  peritoneum  as  a  foreign  body,  cause  a  form  of  chronic  peritonitis 
which  usually  eventuates  in  the  death  of  the  patient.  Life  may  be  prolonged 
by  repeated  laparotomies  and  removal  of  as  much  of  the  growth  as  possible. 
On  the  other  hand,  it  occasionally  happens  that  after  the  removal  of  the  greater 
part  of  the  masses  the  remainder  disappear  spontaneously. 


Fig.  14.3. — Papillary  Cystadenoma  of  the  Ovary. 

High  power  to  show  an  early  stage  in  the  papillary  formation.     In  the  gland  on  the  left  can  be  seen 

tufts  of  epithelium  growing  out  into  the  cavity  of  the  cyst. 


Cystadenoma  Serosum. — The  serous  cystadenomata,  like  those  of  the  pseudo- 
mucinous variety,  are  usually  multilocular,  though  the  number  of  chambers  is 
much  less  than  in  the  former.  Many  times  they  appear  macroscopically 
monolocular,  but  microscopic  evidence  of  daughter  cysts  may  be  found  in  the 
wall.  These  tumors  are  characterized  by  being  filled  with  a  clear,  yellowish, 
serous  fluid,  entirely  free  from  pseudomucin  and  extremely  rich  in  albumin. 
The  cysts  are  lined  with  a  low  cylinder  epithelium,  which  is  usually  ciliated,  and 
which  closely  resembles  in  size  and  form  the  epithelium  of  the  uterine  and  tubal 
mucosa.  Most  of  the  serous  cystadenomata  show  a  papillary  proliferation  of 
the  lining  epithelium. 


394 


GYNECOLOGY 


-':rJ)'-:'''?i^'??i/OAf,';i;!.':^.  fe^'.'V  ^ 


Fig.  144. — Epithelial  Inclusion  in  the  Ovary. 
Low  power.  This  drawing  illustrates  one  method  of  the  formation  of  a  cj'stadenoma.  A  deep 
siilcus  is  seen  in  the  cortex  of  the  ovary,  which  is  lined  by  the  epithelium  peculiar  to  the  ovary.  At 
the  bottom  to  the  right  are  seen  several  gland-like  formations,  the  epithelium  of  which  is  higher  and 
in  process  of  proliferation.  These  glands  may  be  formed  by  the  end  of  such  a  sulcus  being  pinched 
off.  Then  if  proliferation  takes  place  a  cystadenoma  may  be  formed.  To  the  left  the  line  of  demarca- 
tion between  the  cortex  and  the  rest  of  the  ovarian  stroma  is  well  shown. 


The  papillary  process  may  appear  both  in  the  inner  hning  of  the  cj^st  and 
on  the  outer  surface.     In  both  cases  the  histologic  appearance  of  the  epithelial 


NEW    GROWTHS 


395 


cells  is  the  same,  namely,  that  of  a  low,  cylinder  ciliated  epithelium,  though  the 
ciha  are  apt  to  be  wanting  in  exposed  portions  of  the  outer  papillary  growths 
and  if  they  become  carcinomatous. 

The  serous  cystadenomata,  in  contrast  to  the  pseudomucinous,  have  a  tend- 
ency to  grow  in  both  ovaries,  although  the  process  may  not  he  contemporaneous  in 
the  tioo,  a  fact  that  must  always  be  borne  in  mind  by  the  surgeon.  Another 
unfavorable  characteristic  which  the  serous  cystadenomata  possess  in  com- 
imrison  with  the  pseudomucinous  is  that  they  are  apt  not  to  be  supplied  with 
good  pedicles,  but  have  a  tendency  to  develop  through  the  hilus  of  the  ovary 


Fig.  145. — Epithelial  Inclusion  in  the  Ovary. 
High  power.     A  gland-like  formation  found  in  the  cortex  of  ah  ovary  which  may  be  the  beginning  of 

a  cystadenoma  of  the  ovary. 


between  the  leaves  of  the  broad  ligament.  In  this  confined  position  they  not 
only  cause  more  symptoms  of  pain  and  pressure,  but  are  more  difficult  and 
dangerous  to  remove.  The  serous  cystadenomata  grow  more  slowly  than  the 
pseudomucinous  type  and  do  not  reach  as  large  a  size. 

The  clinical  significance  of  serous  cysts  depends  very  much  on  whether  or 
not  they  are  papillomatous.  The  non-papillary  variety  is  usualty  benign  and 
does  not  recur  after  operation,  but  it  is  possible  that  an  apparently  non-papillary 
cystoma  may  recur  rapidly  in  cancerous  form,  the  papillary  growth  having  ex- 
isted microscopically  in  the  wall  of  the  original  tumor. 


396 


GYNECOLOGY 


The  papillary  tumors  are  of  more  serious  clinical  importance  because  of  their 
greater  tendency  to  malignant  degeneration,  and  because  of  the  possibility  of 
implantation  papillomata  on  the  peritoneum.  This  results  always  in  an  ascites 
that  may  become  prodigious. 

It  sometimes  happens  that  after  removal  of  the  main  cyst  the  seed  papillo- 
mata of  the  peritoneum  spontaneously  disappear.  In  other  cases  they  remain 
and  the  ascites  rapidly  reappears. 

The  origin  of  the  ovarian  cystadenomata  is  a  subject  of  much  interest. 
It  was  formerly  thought  that  these  tumors  are  derived  from  isolated  rests  of 


i^/«       d 


u    ■ 


u.»  **'\*': 


%y'} 


u^ 


^ 

•^.c 


■U^   i 


/ 


'fi, 


.^1 


■;ii;>r,';:^i./..ni'U%,.. 


'^< 


^    ;>^#^^'^^^^^'^'^^    ^ 


Fig.  146. — Epithelial  Inclusion  in  the  Ovary. 
High  power  from  the  previous  drawing.     The  cells  lining  the  cavity  have  become  higher  and  have 
larger  nuclei  than  the  normal  ovarian  epithelium. 


the  Wolffian  or  Mliller's  ducts  which  are  sometimes  found  in  the  ovary.  This 
theory  seems  unhkely,  because  the  above-named  rests  do  not  produce  like  tumors 
in  locations  other  than  the  ovary. 

It  has  been  estabhshed  beyond  doubt  that  the  serous  papillary  cystadeno- 
mata spring  from  the  germinal  epithelium  covering  the  ovary.  They  may 
develop  from  papillary  outgrowths  from  the  ovarian  surface,  or  from  glarid- 
hke  inclusions  that  result  from  a  dipping-in  of  the  epithelium  into  the  substance 
of  the  ovary. 


NEW    GROWTHS 


397 


It  has  been  the  fortune  of  the  author  to  secure  from  an  operation  performed 
for  pelvic  inflammation  a  specimen  of  very  early  papillary  serous  cystadenoma 
involving  both  ovaries,  in  which  it  is  clearly  evident  that  the  growth  in  both 
ovaries  is  developing  from  the  germinal  epithelium,  both  from  the  surface  and 
from  inclusions  in  the  stroma.     (See  Figs.  148,  149.) 

The  origin  of  the  pseudomucinous  cysts  is  not  as  well  estabhshed  as  that 
of  the  serous  type,  but  there  is  good  evidence  to  show  that  these  tumors  also 
spring  from  the  germinal  epithelium. 


Fig.  147. — Epithelial  Inclusion  in  the  Ovary. 
Low  power.     This  illustrates  a  possible  beginning  of  a  cystadenoma.     In  this  case  an  adhesion  to 
the  ovary  caused  the  formation  of  the  cavities  seen.     The  epithelial  cells  have  already  lost  the  low 
cuboidal  shape  of  the  normal  ovarian  epithehum  and  are  proliferating,  as  is  seen  in  the  next  drawing. 


The  exciting  cause  of  tumor  formation  in  the  ovaries  is  not  known.  Inflam- 
matory processes  seem  to  have  no  particular  relation  to  their  development. 
They  may  appear  at  any  period  of  life,  even  in  fetal  hfe.  It  seems  probable 
that  the  anlage  from  which  the  cystadenomata  are  derived  dates  back  to  ab- 
normal embryonal  development,  by  which  cefl  inclusions  of  the  germinal  epi- 
thelium are  left  in  the  ovary  that  are  capable  of  lighting  up  into  activity  at  any 
period  of  life.  There  is  a  question  as  to  whether  inflammatory  processes  predis- 
pose to  cyst  formation  of  the  ovary.     Pfannenstiel  believes  that  the  influence 


398 


GYNECOLOGY 


of  inflammation  is  important,  especially  in  malignant  papillary  tumors,  von 
Franque,  on  the  other  hand,  regards  inflammation  as  a  neghgible  factor. 

Carcinoma  of  the  Ovaries.— Gebhard  divides  carcinoma  of  the  ovary  into 
two  classes — (a)  Genuine,  idiopathic  carcinoma,  which  develops  directly  from 
previously  unchanged  ovarian  tissue,  and  (6)  cystic  carcinoma,  which  either 
develops  from  a  benign  ovarian  cyst  (carcinomatous  degeneration)  or  starts  as  a 
cancerous  cyst  from  the  first. 

(a)  The  solid,  or  genuine,  carcinomata  of  the  ovary  are  very  rare,  and  are 
usually  of  the  medullary  type.  They  do  not  grow  to  a  very  large  size.  The 
consistency  of  these  tumors  is  soft,  white,  and  brain-hke,  and  they  have  an 


NmI*,  G-x-ovses 


Pig.  148. — Bilateral  Papillary  Cystadenoma  of  the  Ovaky. 
Drawing  from  a  specimen  removed  at  operation  by  the  author.  On  the  left  is  seen  a  papillary 
cauliflower-like  growth  springing  from  a  small  multUocular  cyst  of  the  ovary  which  can  be  seen  just 
below  and  to  the  right  of  the  cauliflower  mass.  Some  of  the  excrescences  show  cystic  formation.  On 
the  right  is  seen  a  tube  and  ovary  united  by  inflammatory  adhesions.  The  ovary  has  the  appearance 
of  ordinary  cystic  degeneration.  It  was  found  bj'  microscopic  examination  that  this  ovarj-  is  a  verj- 
early  papillary  cystadenoma,  the  growth  of  which  is  entirely  inverting  instead  of  everting,  as  on  the 
opposite  side.  As  will  be  seen  bj'  reference  to  the  microscopic  dra-\vings  (Figs.  149  and  150),  this 
specimen  shows  extraordinarily  well  the  way  in  which  the  papillarj^  cystadenoma  develop  from  the 
germinal  epithelium  covering  the  ovary. 

especial  tendency  to  various  kinds  of  degeneration,  so  that  cj^st  formation  is 
often  found.  Microscopically,  the  medullary  cancers  often  show  a  tendency 
to  adenomatous  growth.  These  cancers  become  dangerous  when  they  have 
broken  through  the  outer  capsule,  in  which  case  the  disease  is  disseminated 
throughout  the  abdominal  cavity. 

(6)  Cystic  Carcinoma. — The  cystic  carcinomata  may  start  as  malignant 
tumors,  or  they  may  represent  a  carcinomatous  degeneration  of  a  benign  papil- 
lary cystadenoma.  The  appearance  of  a  mahgnant  papillary  cyst  so  closely 
resembles  that  of  the  benign  cystomata  that  often  they  can  hardly  be  differ- 
entiated macroscopically.  The  contents  of  a  cancerous  cyst  are  apt  to  be  opaque 
or  bloody,  due  to  desquamation  and  breaking  ofi"  of  the  papillarj^  excrescences. 


NEW    GROWTHS 


399 


Microscopicallj%  the  anatomic  appearance  resembles  closely  that  of  cancer 
of  the  body  of  the  uterus. 

Serous  cystadenomata  are  much  more  prone  to  undergo  carcinomatous  de- 
generation than  is  the  pseudomucinous  variety,  especially  if  they  show  tendency 
to  papillary  growth.  According  to  Pfannenstiel,  at  least  one-half  of  the  papil- 
lary cysts  of  the  ovarj^  are  malignant,  and,  as  they  cannot  always  be  distin- 
guished from  the  benign  form,  all  papillary  cystadenomata  of  the  ovaries  should 
be  surgically  treated  as  if  they  were  malignant.     Clinically,  the  cystic  carcinomata 


Fig.  149. — Serous  CYSTADENOM-i  of  the  Ovary. 
Low  power  of  a  papilla.  The  top  of  the  papilla,  at  the  right,  is  very  edematous  as  compared  with 
its  base,  at  the  left.  The  tips  of  the  papillEe  may  become  so  edematous  as  to  appear  cystic.  The 
epithelial  covering  maj-  consist  of  one  to  se^•eral  layers  of  cells  which,  in  the  inverting  type,  where  the 
papUla  lies  in  a  cyst,  may  show  cilia.  Dilated  Ijoiiph-spaces  are  seen  in  the  tip  near  the  center,  and  a 
gland  to  the  right.     Above  is  a  further  branch  of  the  papilla. 


are  extremelj^  malignant,  and  tend  to  recurrence  even  when  thej^  are  apparently 
entirely  removed  by  operation. 

(c)  Metastatic  Carcinoma  of  Ovary. — It  should  be  remembered  that  many 
cancers  of  the  ovarj^  are  secondary  to  cancers  of  other  organs,  such  as  the  stom- 
ach, gall-bladder,  intestines,  breast,  uterus,  and  tubes,  and  have  the  anatomic 
characteristics  of  the  original  tumor.  It  is  a  matter  of  debate  as  to  how  the 
ovary  becomes  secondarily  involved  by  malignant  growths  starting  so  far  away 
as  the  stomach  or  gall-bladder  without  infection  of  intervening  organs.     There 


400 


GYNECOLOGY 


are  two  theories  to  explain  this:  one  that  the  disease  travels  by  a  retrograde 
transportation  through  the  lymph-channels,  and  the  other  that  the  cancer 
cells  of  the  original  tumor  escape  into  the  peritoneal  cavity  and  are  carried  by 
gravity  and  the  peristaltic  movements  of  the  intestines  to  the  surface  of  the 
ovaries,  where  they  become  implanted  in  the  ovarian  stroma  by  passing  between 
the  cells  of  the  outer  layer  of  germinal  epithehum.  Kraus  has  shown  by  experi- 
ments on  animals  that  inorganic  particles  (carbon,  etc.)  injected  into  the  upper 


.'.i.^^-. 


Fig.  150. — Serous  Cystadenoma  of  the  Ovary. 
Low  power.  To  show  inclusions  of  germinal  epithelium  in  the  stroma  of  the  ovary.  Two  of 
these  are  seen.  If  the  epithelium  lining  the  inclusion  is  compared  with  the  surface  epithelium  seen 
above,  the  activity  of  the  former  is  understood.  The  cells  are  higher,  the  nuclei  larger  and  stained 
deeper.  These  inclusions  at  first  are  circular  or  oval  in  shape.  The  one  on  the  right  shows  the  begin- 
ning oi  the  inversion  of  the  wall  into  the  stroma  of  the  ovary,  with  also  a  beginning  papilla  in  the 
center  of  the  lower  edge. 

peritoneal  cavity  may  be  found  later  actually  invading  the  ovarian  tissue 
through  the  interstices  of  the  germinal  epithelium. 

When  cancer  of  the  "Svary  occurs  in  association  with  malignant  disease  of 
neighboring  organs,  hke  the  uterus  or  tubes,  it  is  often  difficult  to  determine 
in  just  which  organ  the  disease  was  primary.  This  is  due  to  the  fact  that  adeno- 
carcinoma of  the  uterine  and  tubal  mucosa  may  exactly  resemble  adenocar- 
cinoma originating  from  the  gland  inclusions  of  the  germinal  epithehum  of  the 
ovary,  the  fundamental  tissue  being  in  all  three  cases  embryologically  identical. 


NEW    GROWTHS 


401 


Pfannenstiel  makes  the  following  statement:  "It  seems  probable  that  when 
ovarian  cancer  is  associated  with  cancer  of  a  similar  type  in  distant  organs  the 
disease  of  the  ovary  is  usually  secondanj,  while  it  is  more  commonly  primary 
when  the  associated  cancer  is  in  neighboring  organs  like  the  tubes  or  uterus." 

Ovigenous  Tumors  of  the  Ovaries. — There  are  two  forms  of  ovarian  tumors, 
the  dermoids  and  teratomata,  that  can  be  classified  neither  as  parenchymatous 
nor  as  stromatogenous,  in  that  they  develop  from  germ-cell  elements  and  con- 
tain in  their  structure  tissues  of  all  three  germinal  layers.  They  are,  therefore, 
very  appropriately  called  ovigenous  or  ovulogenous. 


Fig.  151. — 'Serous  Cystadenoma  op  the  Ovary. 
High  power  of  an  inclusion  of  germinal  epithelium.     The  epithelial  cells  are  cylindric,  crowded 
together,  irregularly  placed,  and  contain  large  nuclei.    The  basement-membrane  is  absent.     Several 
of  the  cells  are 'swollen;  their  nuclei  are  large,  contain  definite  nucleoli,  and  appear  like  germ  cells. 


Dermoid  cysts  constitute  from  5  to  10  per  cent,  of  all  ovarian  tumors.  They 
may  occur  only  in  one  ovary  or  bilaterally.  Rarely  they  are  multiple,  as  many 
as  eleven  having  been  seen  in  one  ovary  and  twenty-one  in  both  ovaries  (von 
Franque).  They  are  practically  always  monolocular,  and  ordinarily  do  not 
grow  much  larger  than  a  man's  fist,  though  occasionally  they  develop  into  very 
large  tumors. 

The  cysts  always  contain  sebaceous  material,  which  is  fluid  at  the  body 
temperature,  but  thick  and  doughy  when  cooled.     In  one  or  more  parts  of  the 

26 


402 


GYNECOLOGY 


wall  can  be  found  thickened  areas,  the  so-called  "dermoid  plugs,"  which,  on 
microscopic  examination,  exhibit  the  various  structures  of  the  skin  and  corium. 
From  these  epidermal  areas  stream  masses  of  hair  which  may  or  may  not  be 
of  the  same  color  as  that  of  the  patient  who  harbors  the  tumor.  Hair  is  present 
in  nearly  all  of  the  tumors.  Next  to  hair,  irregularly  formed  bony  structures  are 
most  commonly  encountered.  Section  of  the  dermoid  plug  often  shows  rudi- 
mentary and  ill-assorted  but  easily  recognizable  tissues  from  entoderm,  ecto- 
derm, and  mesoderm,  such   as  nerve-ganglia,  nerve-fibers,  glandular  elements 


.    A^^-.-:    ^^. 


Fig.  152. — Serous  Cystadexoma  of  the  Ovaet. 
Low  power.  This  section  is  taken  from  the  surface  of  an  ovary  which  contained  a  serous  cyst- 
adenoma  and  shows  the  activity  of  the  epitheUuni  covering  the  ovary.  The  cells  are  becoming 
cylindric  in  shape,  the  nuclei  are  larger  and  stain  stronger.  At  one  point  the  beginning  of  a  papilla 
is  seen,  the  stroma  is  growing  out,  pushing  the  epithelium  with  it.  The  stroma  is  edematous  and 
contains  many  dilated  blood-vessels. 


from  the  respiratory  and  alimentary  tracts,  breast  tissue,  etc.,  in  addition  to 
the  hair  and  bone  above  mentioned.  The  stage  of  development  of  the  various 
tissues  corresponds  roughly  to  the  age  of  the  patient.  The  most  completely 
formed  structures  are  usuallj^  of  ectodermal  origin,  from  the  cranial  parts, 
such  as  hair,  parts  of  the  jaw,  teeth,  parts  of  the  skull  and  brain,  the  eyes,  the 
glottis,  and  trachea.  A  crudely  rudimentary  fetus  maj^  be  seen.  No  sign  of 
fetal  membranes  has  ever  been  observed.  The  part  of  the  inner  cyst  wall  not 
occupied  by  the  dermoid  plug  is  lined  with  a  low  epithelium,  like  that  of  a  simple 


NEW    GROWTHS 


403 


follicle  cyst,  or  the  epithelial  elements  may  be  absent.  The  inner  wall  may  show 
a  form  of  granulation  tissue  resulting  from  irritation  of  the  hair  or  of  rough  bony 
parts. 

Dermoid  cysts  grow  very  slowl}^  and,  in  contrast  to  teratomata,  have  only 
a  slight  tendency  to  become  mahgnant.  Mahgnant  change  may,  however, 
take  place  in  some  part  of  the  included  tissue,  most  conmionly  of  the  epidermoid 
type,  and  next  frequently  from  included  thyroid  tissue.  Dermoids  are  not 
infrequently  found  in  connection  with  pseudomucinous  cysts.  On  account  of 
this  association  it  has  been  suggested  that  the  pseudomucinous  cyst  is,  in  reality, 


Fig.  153. — Papillary  Adenocarcinoma  of  the  Ovary. 
Low  power.     This  section  shows  the  glands  with  the  thin  trabeculse  of  stroma  between  them. 
These  glands  are  lined  by  a  single  layer  of  cells,  but  often  several  layers  are  found  and  sometimes  the 
lumen  is  filled.     In  the  upper  part  the  papillary  formation  is  shown. 


an  embryonic  tumor,  the  similarity  of  its  secreting  cells  to  those  of  the  intestinal 
tract  indicating  an  origin  from  the  entoderm. 

Dermoid  cysts  are  apt  to  have  long  pedicles,  doubtless  the  result  of  their 
slow  growth.  They  are,  therefore,  particularly  prone  to  torsion,  especially 
when  associated  with  pregnancy.  On  account  of  their  tendency  to  torsion, 
they  frequently  become  inflamed  and  adherent  to  neighboring  organs.  Necrosis 
of  the  cyst  wall,  especially  when  adherent  to  bladder  or  rectum,  is  apt  to  occur, 
with  consequent  fistulous  openings  into  these  organs. 


404 


GYNECOLOGY 


The  cyst  content  is  proteolytic  and  corrosive,  and  when  discharged  into 
the  abdomen  by  rupture  of  the  cyst  wall  is  conducive  to  peritonitis. 

The  teratomata  are  rare  tumors  allied  in  their  structures  to  the  dermoids 
in  that  all  three  germinal  layers  are  represented.  Unlike  the  dermoids,  however, 
they  are  essentially  malignant.  The  tissue  elements  are  mingled  indiscrimi- 
nately, and  for  the  most  part  represent  an  embryonal  stage  of  development. 
The  tumors  grow  rapidly  and  metastasize  freely.  They  reach  a  large  size,  are 
irregular  in  contour  and  solid  in  consistency,  with  occasional  great  cystic  cavi- 


\«  "Saa 


Fig.  154. — Caecinoma  of  the  Ovaey. 
Low  power.     This  illustrates  the  solid  carcinoma  of  the  ovary  consisting  of  alveolar  masses  of  cells 

growing  in  the  stroma  of  the  ovary. 


ties.  Microscopically,  all  tissues  of  the  body  are  found  mingled  in  a  lawless 
growth. 

Less  than  50  cases  of  teratoma  of  the  ovary  are  found  in  the  hterature. 

Struma  ovarii  is  a  term  apphed  to  tumors  of  the  ovary,  which  in  their  histo- 
logic appearance  and  by  the  iodin  test  are  proved  to  be  thj^roidal  in  character. 
These  tumors  are  often  mahgnant,  produce  ascites,  and  tend  to  metastasize. 
There  has  been  much  speculation  as  to  their  origin,  it  being  at  first  supposed 
that  they  represent  a  metastasis  from  the  thyroid  gland  tissue.     It  is  now 


NEW    GROWTHS 


405 


believed  that  the}'  constitute  a  special  form  of  teratoma  (Pf annenstiel) ,  or  that 
thej'  represent  malignant  degeneration  of  thjToid  tissue  included  in  a  dermoid 
e3'st  (von  Franciue). 

It  was  formerly  thought  that  dermoid  cysts  and  teratomata  represent  a 
form  of  incomplete  parthenogenesis,  but  this  idea  has  been  somewhat  modified. 
It  is  now  supposed  that  the  dermoid  does  not  develop  from  a  true  germ-cell  or 
ovum,  but  from  a  blastomere,  which  at  an  early  time  had  been  separated  from 


Fig.  155. — Colloid  Carcixoil^  of  the  Ovary. 
Low  power.     Scattered  through  the  section  are  glands,  Hned  by  a  single  layer  of  high  cells. 
Many  of  the  glands  are  filled  -n-ith  mucus.     The  rest  of  the  tissue  consists  of  ovarian  stroma.     This 
growth  was  metastatic  from  a  carcinoma  of  the  sigmoid  and  the  glands  are  characteristic  of  that. 

the  original  germ-cell  bundle.  The  isolation  of  such  a  blastomere  if  transported 
awaj'  from  its  original  location  accounts  also  for  the  dermoid  and  teratoid 
tumors  found  in  other  parts  of  the  bodj". 


This  theory  may  be  better  understood  from  the  following  abstract  from  Opitz  and  Menge : 

A  number  of  facts  seem  to  contradict  the  theory  that  the  dermoid  and  teratoid  tiunors 

spring  parthenogenetically  from  an  unfertilized  ovimi.     Chief  among  these  are  the  appearance 

of  these  tumors  in  parts  of  the  body  far  distant  from  the  ovary,  and  also  their  development  in 

men  not  only  in  the  testis,  but  in  other  parts  of  the  bodj'.     Further,  the  structure  of  the  tissues 


406 


GYNECOLOGY 


of  a  dermoid  corresponds  in  a  general  way  to  the  age  of  the  patient  who  carries  it.  Also  the 
absence  of  fetal  membranes,  which  normally  are  developed  before  any  of  the  other  tissues  found 
in  dermoids,  contradicts  the  theory  of  origin  from  an  unfertilized  egg. 

Finally,  if  it  were  possible  for  a  dermoid  to  spring  from  an  unimpregnated  egg  one  would 
expect  a  much  greater  frequency  of  these  tumors,  considering  the  enormous  number  of  unfertil- 
ized eggs  that  pass  the  tube.  Nevertheless,  only  5  authentic  cases  of  dermoids  in  the  tubes 
have  been  reported. 

Since  the  dermoids  and  teratomata  contain  constituents  from  all  three  germinal  layers 
(entoderm,  ectoderm,  mesoderm),  it  must  be  that  they  spring  from  cells  that  "stand  close  to" 


Fig.  156. — Colloid  Carcinoma  of  the  Ovary. 
High  power  of  the  section  shown  in  the  previous  drawing.     This  shows  the  typical  cylindric 


epithelium  associated  with  the  large  intestine, 
lea^dng  spaces. 


The  epithelium  has  fallen  out  of  many  of  the  glands, 


the  fertihzed  ovum.  This  requirement  is  met  by  the  so-called  blastomeres,  which  are  the 
products  of  the  first  cell  division  of  the  impregnated  egg,  and  which  experimentation  on  the 
lower  animals  has  shown  have,  when  isolated,  the  power  of  producing  rudimentary  embryos. 
It  is  readily  conceivable  that  in  the  complicated  processes  of  growth  of  the  earliest  embryonal 
time  some  of  these  cells  may  be  displaced  to  the  most  diversified  parts  of  the  developing  organ- 
ism. 

It  has  been  proved  by  animal  experimentation  that  the  earhest  segmentation  divides  the 
ovum  into  two  kinds  of  blastomeres,  those  which  become  the  later  germ-cells  (ova  or  spermato- 


NEW    GROWTHS 


407 


zoa)  and  those  which  enter  into  the  construction  of  the  bodj^  (somatic  cells).  It  is  conceivable 
that  from  some  irregularity  of  development  and  arrangement  of  the  primary  cells  a  somatic 
blastomere  ma}'  become  displaced  and  included,  for  example,  in  the  ovary,  where  it  may  either 
be  destroj-ed  undeveloped  or,  imder  the  irritating  influence  of  some  chemical  change  in  the 
blood  or  sm-rounding  tissue  substance,  be  awakened  later  from  its  dormant  state  into  produc- 
tive acti%'ity,  and  create  a  dermoid  cyst  or  a  teratoma.     (Free  translation.) 

Stromatogenous  Tumors  of  the  Ovary. — The  stromatogenous  tumor.s  spring 
from  the  connective-tissue  stroma  with  which  the  ovary  is  richly  supplied. 


Fig.  157.— Colloid  Carcinoma  of  the  Ovary.     (Metastatic.) 
High  power.     This  shows  the  large  cells  with  the  eccentrically  placed  nucleus  characteristic 
of  Krukenberg's  tumor.  When  cut  in  the  right  plane,  as  in  the  lower  right  and  middle  parts  of  the 
drawing,  they  have  the  appearance  of  a  seal  ring. 


The  benign  tumors  are  represented  by  tlie  fibromata,  which  appear  either 
as  small  circumscribed  growths  or  as  diffuse  neoplasms  forming  large  solid 
tumors. 

The  circumscribed  fibromata  represent  a  local  Iwperplasia  of  the  ovarian 
stroma,  which  in  some  cases  can  with  difficulty  be  differentiated  from  the 
fibrous  changes  of  an  interstitial  oophoritis.     In  other  cases  the  fibromatous 


K^,. 


""w^fr^ 


Fig.  158. — Dermoid  Cyst. 
Very  low  power.     Section  of  the  whole  ovary.     On  the  right  is  a  white,  well-defined  area  which 
is  a  small  dermoid  cyst.     Its  contents  consist  of  yellowish,  greasy  material  containing  hair.     The 
three  cavities  below  are  small  follicular  cysts  and  the  one  above  to  the  left  is  a  corpus  luteum. 


nmrKfta  couciEL 


Fig.  159.— Dermoid  Cyst. 
Very  low  power.  Section  of  the  small  dermoid  cyst  shown  in  the  last  drawing.  This  shows  the 
so-called  plug  of  the  dermoid  cyst  extending  into  the  cavity.  It  is  covered  with  stratified  squamous 
epithelium  under  which  are  sebaceous  glands  and  hair-follicle.  A  hair-follicle  can  be  seen  to  the  left 
of  the  middle  of  the  plug  near  its  surface.  This  is  a  very  early  stage  in  the  development  of  a  dermoid 
cyst.     They  are  seldom  found  so  small. 

408 


NEW    GROWTHS 


409 


growth  is  near  the  surface,  and  appears  as  a  tuberous  or  papillary  wart-like 
excrescence.  Another  form  of  circumscribed  fibroma  has  its  origin  in  a  corpus 
luteum.  These  tumors  have  a  definite  capsule.  They  have  a  dense  fibrous 
central  structure  surrounded  bj"  a  cortex  of  yellow  or  reddish-j-ellow  color,  in 
which  lutein  cells  can  be  demonstrated. 

The  circumscribed  fibromata  have  very  little  clinical  significance.     Diffuse 
fibromata  represent  a  general  hyperplasia  of  the  ovarian  stroma,  which  pro- 


FiG.  160. — Dermoid  Cyst. 
High  power.     Showang  the  edge  of  the  plug  which  is  covered  with  stratified  squamous  epithelium. 
At  the  middle  is  the  entrance  to  a  hair-follicle,  the  continuation  of  which  is  seen  below  in  the  center 
of  the  drawing.     The  stroma  consists  of  connective  tissue  infiltrated  with  a  few  leukocytes. 

duces  a  large  solid  tumor  that  always  preserves  an  ovarian  contour.  Cross- 
section  shows  a  whitish  dense  homogeneous  connective-tissue  substance.  Often 
the  tissue  is  softened  by  edematous  infiltration  of  the  lymph-spaces,  which, 
microscopically,  gives  the  appearance  of  myxomatous  tissue.  The  edematous 
infiltration  may  be  so  extensive  as  to  form  cystic  cavities  filled  with  clear 
colorless  fluid.     Occasionally  hemorrhagic  areas  are  seen. 


410 


GYNECOLOGY 


Muscle-fibers  have  been  demonstrated  by  good  authorities  in  these  tumors, 
but  their  presence  is  rare. 

Diffuse  fibromata  may  grow  to  a  very  large  size.  They  are  characterized 
even  when  of  moderate  size  by  causing  ascites;  though  in  what  way  this  is 
brought  about  is  not  known.     Pfannenstiel  ascribes  the  ascites  to  a  chemical 


Fig.  161. — Round-cell  Sarcoma  of  the  Ovahy. 
Low  power.     The  upper  part  of  the  dramng  shows  the  tumor,  characterized  by  its  round  cells 
lying  close  together.     There  are  many  blood-vessels  scattered  through  it.     The  light  band  is  part  of  a 
corpus  albicans  and  at  the  bottom  is  a  small  area  of  normal  ovarian  stroma. 


irritation  of  the  peritoneum.  Schauta  considers  it  to  be  due  to  pressure  and 
stasis  of  the  blood-vessels  of  the  parametrium. 

The  diffuse  fibromata  may  undergo  sarcomatous  degeneration. 

Sarcoma. — Sarcomata  of  the  ovary  are  rare  tumors.  They  may  originate 
as  a  mahgnant  growth,  or  they  may  represent  a  degeneration  of  a  fibroma. 
In  about  one-fourth  of  the  cases  reported  they  occur  bilaterally.  They  closely 
resemble  ovarian  fibromata,  and  can  often  be  distinguished  from  them  only 
by  the  microscope.     Ascites  is  always  present,  but  this  is  not  a  special  mark 


NEW    GROWTHS 


411 


of  malignity,  because  it  is  usually  associated  with   all   solid  tumors  of  the 
ovary. 

The  sarcomata  have  an  early  tendency  to  metastasis,  which  takes  place 
into  the  retroperitoneal  lymph-glands,  and  finally  on  the  visceral  and  parietal 
peritoneum.  Anatomically,  these  tumors  ma}'-  be  of  the  spindle-cell  or  round- 
cell  variety  of  sarcoma.  The  former,  according  to  Gebhard,  are  smaller,  have 
less  tendency  to  metastasize,  and  occur  at  a  more  advanced  age  than  the  latter, 


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f^i*i7  %"r6#^-:^ 


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Fig.  162. — Round-cell  Sarcoma  of  the  Ovary. 
High  power.     The  tumor  is  made  up  of  large  round  cells  containing  round  or  oval  nuclei  which 
Afary  considerably  in  size.    The  nuclei,  stained  deeplj-,  are  in  the  first  stage  of  mitosis.    Three  blood- 
vessels are  seen. 

and  closely  resemble  fibromata,  from  which  they  are  sometimes  to  be  distin- 
guished with  difficulty.  The  round-cell  variety  occurs  at  an  earher  age,  often 
in  children,  and  is  much  more  malignant  in  type  than  the  spindle  cell.  These 
tumors  are  especially  liable  to  be  bilateral. 

Included  with  the  sarcomata  are  malignant  tumors  which  spring  from  the 
adventitial  connective  tissue  immediately  surrounding  the  ovarian  blood- 
vessels (perithelioma)  and  from  the  endothelium  lining  the  blood-  and  lymph- 
vessels  (endothelioma).     These  tumors  closely  resemble  the  round-cell  sarco- 


412  GYNECOLOGY 

mata  and,  clinically,  need  hardly  be  distinguished  from  them.     They  are  fre- 
quently cystic. 

In  general,  the  sarcomata  can  be  macroscopically  differentiated  from  fibro- 
mata by  the  softness  of  the  tissue,  which  usually  shows  areas  of  necrosis,  fatty 
degeneration,  and  hemorrhagic  infiltration. 

SYMPTOMS  OF  OVARIAN  TUMOR 

Uncomphcated  tumors  of  the  ovary  may  cause  little  or  no  trouble  until 
they  reach  a  considerable  size.  Tension  on  the  ovarian  substance  by  the  grow- 
ing tumor  seems  to  give  no  pain.  When  the  growths  are  well  pedunculated  and 
very  movable,  they  rise  out  of  the  true  pelvis  as  they  increase  in  size  and  ride 
freely  in  the  lower  abdomen  without  giving  pressure  symptoms  until  their 
weight  becomes  noticeable  or  until  they  become  compHcated  in  some  way. 

If,  however,  the  ovarian  tumor  is  growing  in  between  the  leaves  of  the 
broad  ligament  or  becomes  compHcated  by  pelvic  adhesions  so  that  it  cannot 
move  freely,  pressure  symptoms  appear  early,  consisting  of  a  sense  of  weight 
and  fulness  in  the  pelvis,  backache,  difficulty  in  micturition  or  defecation,  and 
pains  in  the  hips  and  thighs  as  a  result  of  pressure  on  the  pelvic  nerve  plexuses. 
There  may  also  be  evidences  of  passive  congestion  from  pressure  on  the  pelvic 
blood-vessels,  such  as  edema  and  varices  of  the  lower  extremities,  or  of  the 
external  genitals  or  of  the  abdoniinal  wall. 

Intraligamentary  tumors  are  especially  apt  to  interfere  with  the  ureter, 
which  may  be  dislocated  or  compressed,  so  as  to  cause  a  hydro-ureter  or  a 
hydronephrosis.  The  dislocation  of  the  ureter  greatly  increases  the  danger  of 
operation.  The  papillary  cystadenomata  have  a  tendency  to  become  intra- 
ligamentary, while  the  pseudomucinous  cysts,  fibromata,  and  dermoids,  being 
well  pedunculated,  seldom  develop  in  the  broad  Hgament. 

When  ovarian  tumors  reach  a  large  size,  so  as  to  fill  most  of  the  abdominal 
cavity,  symptoms  of  pressure  on  the  intestines,  stomach,  and  diaphragm  appear. 
Digestive  disturbances,  difficulty  in  breathing,  and  a  gradual  emaciation  are 
characteristic.  A  pecuhar  drawn  look  about  the  face  is  commonly  referred  to  as 
the  ovarian  facies. 

Papillary  cystadenomata,  cancerous  cysts,  and  all  sohd  tumors  of  the  ovary 
are  usually  associated  with  ascites.  If  the  ascites  is  bloody  it  usually  indicates 
malignancy.  When  ascites  is  present,  general  pressure  symptoms  appear 
more  quickly  and  are  more  severe. 

Non-malignant  proliferating  tumors  if  not  interfered  with  continue  to 
grow,  and  eventually  cause  the  death  of  the  patient  by  a  general  marasmus. 
Non-proliferating  retention  cysts  if  not  complicated  by  torsion  or  adhesions 
may  be  carried  for  years  without  doing  damage,  though  always  in  danger  of 
complications. 

Rupture  of  ovarian  cysts  occurs  in  a  small  percentage  of  cases.     It  may  be 


NEW    GROWTHS  413 

the  spontaneous  result  of  increasing  internal  pressure  on  a  wall  that  is  gradually- 
being  thinned  out,  or  of  a  necrosis  or  other  degenerative  process  of  the  cyst  wall. 
The  rupture  may  be  caused  by  trauma,  such  as  a  fall  or  kick,  or  violent  ab- 
dominal pressure,  or  from  childbirth,  or  from  a  bimanual  examination.  The 
effect  of  rupture  may  or  may  not  be  serious.  If  it  involves  an  injury  of  the 
large  blood-vessels  of  the  cyst  wall  there  may  be  sudden  fatal  hemorrhage  into 
the  abdominal  cavity.  Otherwise  the  symptoms  of  cyst  rupture  are  slight, 
the  patient  noticing  chiefly  the  sudden  diminution  in  the  protuberance  of  her 
abdomen. 

As  a  rule,  the  ruptured  opening  of  the  cyst  wall  becoming  involved  in  adhe- 
sions closes,  and  the  cyst  again  fills  to  its  former  proportions.  Exceptionally, 
the  opening  persists'  and  the  cyst  secretions  continue  to  pour  into  the  abdominal 
cavity. 


i^f^^W  --"^       "''^"■"■--  T?vgh-tTu£c 


V9'5" 
lletcnt.onCv^sl  "detention  Gust 


Fig.  163. — Double  Ovarian  Cysts,  Showing  Torsion  on  One  Side. 
The  pedicle  has  undergone  one  complete  revolution.     The  cysts  are  of  the  non-proliferating 
retention  type.     In  removing  double  cysts  the  uterus  should  also  be  removed  by  supravaginal  hys- 
terectomy, as  in  the  figure. 

The  most  important  complication  of  ovarian  tumors  is  that  of  torsion, 
which  is  said  to  occur  in  from  10  to  20  per  cent,  of  cases. 

When  the  ovarian  tumor  grows  to  a  certain  size  it  rises  out  of  the  posterior 
part  of  the  true  pelvis  into  the  anterior  part  of  the  false  pelvis.  During  this 
excursion  the  pedicle  of  the  tumor  is  necessarily  turned  in  a  spiral  manner  about 
90  degrees.  This  much  torsion  does  not  ordinarily  cause  symptoms,  but  under 
certain  mechanical  conditions  the  torsion  becomes  increased  until  the  blood- 
vessels of  the  pedicle  are  compressed,  whereupon  symptoms  ensue. 

The  causes  of  torsion  of  ovarian  cysts  are  numerous,  and  are  referred  to 
peristaltic  movements  of  the  intestines,  bodily  movements  on  the  part  of  the 
patient  such  as  result  from  strenuous  labor,  athletic  exercises,  riding,  jars,, 
trauma,  etc.  One  important  cause  is  the  unequal  growth  in  different  parts 
of  the  cyst  wall,  which  encourages  a  twisting  in  the  location  of  the  tumor. 


414  GYNECOLOGY 

During  pregnancy  the  change  in  the  position  of  the  uterus  and  the  fetal  move- 
ments of  the  child  are  frequent  causes  of  torsion. 

As  a  rule,  if  the  amount  of  torsion  reaches  180  degrees,  symptoms  become 
evident.  The  pedicle  may  make  two  or  three  complete  rotations  about  its 
axis,  occasionally  as  many  as  five  or  six.  The  torsion  causes  first  a  compres- 
sion of  the  veins  of  the  pecUcle  without  interfering  with  the  arterial  circulation, 
and  produces  a  sudden  rapid  increase  in  the  size  of  the  tumor  as  a  result  of 
venous  congestion  and  greatly  increased  secretion  from  the  tumor  wall.  The 
obstruction  of  circulation  causes  a  hemorrhage  into  the  lumen  of  cystic  tumors 
and  areas  of  infarction  in  the  tissues  of  sohd  tumors.  The  pearly,  ghstening 
appearance  of  the  surface  of  the  tumor  is  changed  to  a  dull-brown  color,  or  in 
different  shades  to  a  dark  red.  The  damaged  surface  of  the  tumor  soon  becomes 
adherent  to  the  intestines  and  omentum,  and  if  the  patient  continues  to  live 
the  adhesions  eventually  become  organized  and  tenacious. 

The  clinical  appearance  of  torsion  varies  in  proportion  to  the  acuteness 
of  the  condition.  If  the  torsion  takes  place  slowly,  and  does  not  exceed  a  partial 
compression  of  the  venous  circulation  of  the  tumor,  there  may  be  only  moderate 
pain  without  severe  constitutional,  symptoms.  The  symptoms  may  continue 
for  some  time,  usually  accompanied  by  a  very  evident  increase  in  the  size  of 
the  tumor.     The  torsion  may  even  right  itself  with  disappearance  of  symptoms. 

If  the  torsion  is  acute,  the  picture  is  a  stormy  one  and  resembles  that  of 
acute  peritonitis.  The  abdomen  is  rigid  and  chstended  and  extremely  sensitive; 
the  bowels  are  paralyzed  and  the  pulse  is  rapid  and  thread-like.  If  the  tumor 
does  not  become  septic  the  attack  may  pass  off,  to  return  again  at  some  future 
time  unless  the  tumor  is  removed. 

The  future  course  of  the  tumor  is  determined  somewhat  by  the  adhesions 
that  it  forms,  which  may  act  either  in  a  deleterious  or  beneficial  way.  If  the 
tumor  becomes  densely  adherent  to  the  wall  of  the  intestine,  opportunity  may 
be  given  for  the  passage  of  micro-organisms  from  the  lumen  of  the  bowel  through 
the  lymph-spaces  of  the  intestinal  wall  to  the  cyst,  with  resultant  sepsis  and 
peritonitis.  If  the  adhesions  are  chiefly  to  the  omentum,  the  tumor  may  be 
endowed  with  a  fresh  blood-supply,  which  will,  for  a  time  at  least,  maintain' 
its  life  and  integrity. 

During  the  puerperium  ovarian  cysts  not  only  are  especially  hable  to  torsion, 
but  when  torsion  takes  place  there  is  especial  danger  of  infection.  If  the  tumor 
suppurates  it  may  rupture  into  the  abdominal  cavity,  causing  fatal  peritonitis, 
or  it  may  break  into  the  bladder,  rectum,  or  vagina. 

The  menstrual  function  is  not  greatly  disturbed  by  ovarian  tumors.  Even 
very  large  bilateral  growths  retain  enough  of  the  ovarian  parenchyma  to  main- 
tain the  menstrual  flow,  amenorrhea  being  very  rare.  Acute  torsion  of  the 
pedicle  usually  causes  bleeding  from  the  uterus  on  account  of  the  general  pelvic 
hyperemia. 

According  to  von  Franque,  pregnancy  is  interrupted  in  about  20  per  cent. 


NEW    GROWTHS  415 

of  cases  by  the  presence  of  ovarian  tumors,  while  childbirth  is  only  exceptionally 
completely  interfered  with. 

Cancerous  cysts  of  the  ovary  are  usually  attended  with  ascites,  and  the 
chief  symptoms  are  often  due  to  the  pressure  of  the  ascitic  fluid.  If  seed  metas- 
tases are  sown  extensively  on  the  peritoneum  the  pain  may  be  varied  and  severe. 
When  the  tumors  are  malignant  the  cachexia  and  wasting  are  very  marked  and 
rapid. 

DIAGNOSIS  OF  OVARIAN  TUMORS 

Small  and  moderately  sized  cysts  of  the  ovary  are  usually  easily  distin- 
guished. The  smooth,  round  surface  and  cystic  consistency  of  the  tumor  which 
moves  independently  of  the  uterus  are,  as  a  rule,  unmistakable.  If,  however, 
the  cyst  is  very  tense  it  may  be  difficult  to  differentiate  it  from  a  pedunculated 
myoma. 

If  the  cyst  is  intraligamentary  or  adherent  it  is  often  impossible  to  differen- 
tiate it  from  a  sactosalpinx  or  hydrosalpinx  or  a  tubo-ovaritis.  Edematous 
myomas,  and  even  large  organizing  pelvic  hematoceles  from  ectopic  pregnancy, 
are  sometimes  confused  with  ovarian  cysts. 

Solid  tumors  of  the  ovary,  whether  pedunculated  or  not,  are  difficult  to  dis- 
tinguish from  myomas  of  the  uterus. 

Large  ovarian  cysts  occupying  the  abdominal  cavity  are  usuall}^  easily 
diagnosed.  The  lower  pole  of  these  cysts  can  nearly  always  be  felt  by  the 
vaginal  finger  and  a  fluctuation  wave  be  recognized  between  the  two  examining 
hands.  The  uterus  can  be  felt  either  pushed  far  back  in  the  posterior  culdesac, 
or  forced  forward  above  the  level  of  the  pubes  and  to  one  side  of  the  median 
line.  With  the  patient  on  her  back  the  protuberant  abdomen  is  noticeable. 
A  succussion  fluid  wave  can  be  felt  from  side  to  side.  In  this  position'  a  cyst 
rides  upward  toward  the  anterior  abdominal  wall,  while  the  bowels  recede  to 
the  flanks.  On  account  of  the  fluid  contents  of  the  cyst  the  anterior  dome  of 
the  abdomen  is  dull  to  percussion,  while  the  flanks  produce  the  tympanitic  note 
of  the  underlying  intestines.  In  ascites,  on  the  other  hand,  the  light  intestines 
float  on  the  free  fluid  contained  in  the  abdominal  cavity,  and  are  just  under 
the  dome  of  the  abdominal  wall,  while  the  fluid  settles  to  the  back  and  flanks. 
In  ascites,  therefore,  the  dome  of  the  abdomen  is  tympanitic,  while  the  flanks 
are  dull. 

There  are,  however,  conditions  which  present  great  difficulties  in  diagnosis. 
An  ovarian  cyst  combined  with  ascites,  especially  if  adhesions  or  metastases 
are  present,  is  an  example.  Ascites  confined  and  localized  by  adhesions,  such  as 
is  seen  in  tubercular  and  cancerous  peritonitis,  is  another  condition  that  is 
apt  to  cause  confusion. 

Large  tumors  of  the  kidneys  are  sometimes  mistaken  for  ovarian  growths. 
Careful  examination,  however,  usually  reveals  their  true  nature.  Tumors  of 
the  kidney  reach  higher  up  in  the  hypochondrium  than  do  ovarian  tumors,  and 


416  GYNECOLOGY 

only  very  rarely  extend  low  enough  in  the  pelvis  to  be  palpated  by  the  vaginal 
finger.  Most  important  of  an  is  the  examination  of  the  costovertebral 
angle.  Tumors  of  the  kidney  large  enough  to  be  mistaken  for  ovarian 
growths  invariably  cause  a  fulness  in  the  triangular  space  made  by  the 
costovertebral  angle.  This  can  best  be  observed  with  the  patient  in  the  sitting 
position. 

Diastasis  of  the  recti  muscles  is  very  frequently  mistaken  by  the  inexpert  for 
ovarian  cyst,  especially  if  the  patient  has  a  large,  full  abdomen.  The  rapid 
accumulation  of  abdominal  fat  also  often  evokes  a  diagnosis  of  ovarian  tumor. 
Palpation  and  percussion  of  the  abdomen,  coupled  with  a  bimanual  examina- 
tion, readily  clear  up  the  difficulty. 

TREATMENT  OF  OVARIAN  TUMORS 

It  may  be  said  categorically  that  the  treatment  of  all  ovarian  tumors  is 
surgical  removal.  This  rule  applies  even  to  retention  cysts  unless  they  be  very 
smafi.  Retention  cysts  may  of  themselves  be  a  source  of  danger  if  torsion 
occurs,  or  if  they  become  involved  in  a  pelvic  inflammation.  Moreover,  it  is 
impossible  to  tell  by  bimanual  examination  whether  a  given  tmnor  is  a  reten- 
tion cyst  or  a  prohferating  growth.  Proliferating  tumors  of  the  ovary  are 
invariably  progressive  in  their  growth,  and  if  not  removed  eventuallj^  cause  the 
death  of  the  patient  whether  they  are  malignant  or  not.  They  should,  there- 
fore, be  removed  as  early  as  possible. 

It  is  important  that  the  operator  should  have  an  understanding  of  the 
general  pathology  of  ovarian  tumors  in  order  to  use  proper  judgment  in  the 
form  of  operation  to  be  employed.  Simple  retention  cysts,  even  of  large  size, 
if  unilateral  do  not  require  the  removal  of  the  other  ovary.  In  young  women 
retention  cysts  of  moderate  size  may  sometimes  be  resected  so  as  to  leave  a 
small  amount  of  ovarian  parenchyma. 

Retention  cysts  comphcating  pregnancy  should  always  be  removed  on 
account  of  the  special  danger  of  torsion  and  infection.  If  the  cyst  is  discovered 
before  the  third  month  it  is  advisable  to  wait,  if  possible,  until  after  the  third 
month  before  operation  in  order  to  avoid  the  chance  of  causing  an  abortion. 
The  corpus  luteum  has  been  shown  to  preside  over  the  growth  of  the  fetus  for 
the  first  two  and  one-half  to  three  months,  its  destruction  during  that  period 
causing  the  death  of  the  fetus.  As  the  corpus  luteum  is  sometimes  included 
in  the  ovarian  tissue  stretched  out  over  the  surface  of  the  ovary,  an  early  removal 
of  the  cyst  is  likely  to  cause  an  abortion. 

In  operating  on  ovarian  cysts  it  is  extremely  important  not  to  spill  the 
contents  of  the  cyst,  as  one  can  never  be  sure  that  there  may  not  be  a  carcinoma- 
tous growth  on  the  inner  wall,  cells  from  which  may  be  disseminated  by  the 
fluid  in  the  abdominal  cavity.  It  is,  therefore,  best  not  to  evacuate  the  cyst 
before  removal  unless  the  exigencies  of  the  case  make  it  absolutely  compulsory. 


NEW    GROWTHS  417 

This  often  requires  very  long  incisions,  which  do  no  harm  if  carefully  sewed  up. 
It  is  also  important  not  to  rupture  adherent  cysts  during  dissection,  though 
it  is  sometimes  unavoidable.  It  should  be  remembered  that  the  content  of 
dermoid  cysts  has  a  toxic  proteolytic  action  on  fresh  tissues  with  which  it  comes 
in  contact,  especially  on  peritoneal  surfaces. 

The  question  of  the  removal  of  the  other  ovary  in  operating  on  unilateral 
ovarian  tumors  is  always  a  vital  one.  We  have  said  that  the  simple  retention 
cysts  do  not  require  the  removal  of  the  other  ovary.  This  is  true  also  of  all 
the  benign  tumors,  such  as  fibromata,  pseudomucinous  cysto-adenomata,  par- 
ovarial  cysts,  and  the  dermoids.  The  serous  papillary  cystadenomata,  whether 
malignant  or  not,  and  all  tumors  in  which  malignancy  is  suspected  indicate  the 
removal  of  both  ovaries.  As  has  been  stated,  when  both  ovaries  are  to  be  taken 
out,  for  whatever  cause,  the  uterus  should  also  be  removed  by  supravaginal 
hysterectomy. 

The  presence  of  seed  papillomata  on  the  surface  of  the  intestines  does  not 
contra-indicate  extirpation  of  the  original  ovarian  tumor,  for  the  patient's  life 
may  be  greatly  prolonged  by  the  operation,  and  occasionallj^  the  seed  metas- 
tases, even  when  mahgnant,  sometimes  regress  and  disappear  after  the  removal 
of  the  primary  growth. 

Ascites  following  operation  for  papillary  and  malignant  cystadenomata  may 
come  on  rapidly  and  fill  the  abdomen  to  uncomfortable  distention.  It  is  neces- 
sary then  to  tap  the  contents  with  a  trocar  or  to  evacuate  the  peritoneal  cavity 
through  a  small  laparotomy  incision  under  an  anesthetic.  The  latter  method  is 
preferable,  for  the  removal  of  the  contents  can  be  made  much  more  thorough, 
especially  if  they  are  viscid  or  gelatinous  or  contain  particles  of  papillomatous 
tissue. 

Pfannenstiel  (Veit  III,  p.  166)  cites  2  cases  of  Olshausen's  which  lived  six  and  seven  years, 
and  were  tapped  76  and  105  times  respectively.  Pye-Smith  tapped  a  woman  299  times  during 
the  course  of  nine  years,  while  Peaslee  broke  all  records  by  tapping  a  patient  665  times  dm-ing 
thirteen  years.  Pfannenstiel  also  calls  attention  to  t^e  fact  that  the  pleuritic  exudate,  which 
sometimes  accompanies  the  ascitic  cases  of  papillary  cystoma,  usually  disappears  as  completely 
as  the  ascites  after  removal  of  the  main  tumor. 

PROGNOSIS  OF  OVARIAN  TUMORS 

Operations  on  uncomplicated  ovarian  tumors  are  very  successful,  the  mor- 
tahty  being  almost  nil.  The  operation  is  so  simple  and  attended  with  so  httle 
shock  that  it  can  be  done  with  comparative  safety  on  patients  even  of  advanced 
age.  If,  however,  the  tumors  are  ligamentary  or  complicated  with  adhesions 
the  operation  may  be  a  very  serious  one.  The  prognosis  of  the  benign  tumors 
is  almost  absolutely  good  as  to  recurrence,  although  it  must  be  borne  in  mind 
that  some  apparently  benign  growths  are  microscopically  malignant  and  recur 
rapidly.  All  ovarian  tumors  should,  therefore,  receive  a  rigorous  microscopic 
examination. 


418 


GYNECOLOGY 


The  prognosis  of  malignant  cystadenomata  is  bad,  though  hfe  may  some- 
times be  prolonged  for  a  surprising  period  of  time.  At  other  times,  especially 
when  the  cyst  contents  are  spilled  in  the  abdominal  cavity,  the  recurrence  is 
very  rapid  and  destructive. 

Removal  of  ovarian  tumors  of  one  side  may  be  followed  by  the  growth 
of  a  similar  tumor  of  the  other  side,  even  many  years  after.  This  is  true  of  all 
the  ovarian  tumors,  from  retention  cysts  to  carcinomata. 

PAROVARIAN    CYSTS 

The  parovarium  is  a  small  glandular  strand  of  tissue  lying  close  to  the  tube 
between  the  leaves  of  the  broad  ligament.     It  can  be  seen  by  holding  the  tube 


Fig.  164. — Parovarium. 
Low  power.     Several  tubules  of  the  parovarium  are  seen  cut  in  cross-section.     They  are  lined 
by  a  single  layer  of  low  cells- and  lie  in  the  broad  ligament  between  the  ovary  and  tube.     Cysts  may 
develop  from  them. 


so  as  to  allow  the  Hght  to  pass  through  the  translucent  mesosalpinx.  It  is  shaped 
somewhat,  like  a  comb,  the  back  of  which  is  parallel  to  the  tube  near  the  outer 
segment,  while  the  teeth  converge  in  the  direction  of  the  hilum  of  the  ovary. 


NEW    GROWTHS  419 

This  structure,  made  up  of  small  canals,  possesses  a  fibromuscular  wall  (Geb- 
hard)  arid  minute  lumina  lined  with  a  low  cuboidal  ciliated  epithelium.  The 
parovarium  represents  a  remnant  of  the  sexual  part  of  the  Wolffian  body,  its 
function  not  being  known. 

The  tumors  of  the  parovarium  are  almost  exclusively  cysts,  and  are  dotibt- 
less  formed  by  an  abnormal  secretion  of  the  fining  epithelium.  They  are,  for 
the  most  part,  to  be  regarded  as  retention  cysts  and  not  as  proliferating  growths. 
A  cystic  dilatation  of  the  bfind  end  of  the  parovarium  near  the  tubal  ostium  is 
very  common,  and  becoming  pedunculated  has  the  appearance  of  a  cyst  of 
Morgagni.  Larger  cysts  may  form  between  the  leaves  of  the  broad  ligament 
and  sometimes  reach  a  very  considerable  size.  The  tube  and  ovary  are  stretched 
out  over  the  surface  of  the  tumor.  Parovarian  cysts  can  be  distinguished  from 
intraligamentary  ovarian  cysts  by  the  presence  of  the  ovary  attached  to  the  wall. 
The  outer  layer  of  the  wall  of  the  tumor  is  c'omposed  of  the  connective  tissue 
and  peritoneal  covering  of  the  broad  ligament  leaf.  This  layer  can  be  easily 
stripped  from  a  second  well-defined  layer  which  constitutes  the  real  outer 
wall  of  the  cyst.  This  wall  is  made  up  of  connective  tissue  and  smooth  muscle- 
fibers  (Gebhard),  being  lined  with  a  single  layer  of  low  ciliated  epithelium. 
Parovarian  cysts  are  nearly  always  unilocular,  and  contain  a  clear  serous  fluid, 
which,  as  the  tumor  increases  in  size,  becomes  turbid  and  yellow  or  brown  in 
color. 

The  inner  surface  is  -often  raised  in  folds  that  have  a  papillary  appearance, 
but  the  cysts  rarely  if  ever  become  malignant. 

Although  growing  in  the  broad  ligament,  tjie  parovarian  cysts  are  often  pe- 
dunculated and  are  subject  to  torsion.  They  grow  slowly  and  do  not  produce 
symptoms  unless  their  pedicles  become  twisted  or  unless  they  grow  to  a  size 
sufficiently  large  to  cause  pressure.  They  cannot  be  climcally  differentiated 
from  ovarian  cysts.  -    ■ 

The  treatment  is  extirpation.  The  small  cysts  if  pedunculated  are  easily 
removed.  If,  however,  they  have  grown  downward  within  the  leaves  of  the 
broad  hgament  their  extirpation  may  be  attended  with  much  difficulty.  Especial 
care  must  be  taken  not  to  injure  the  ureters.  If  it  is  impossible  to  remove  all  of 
the  cyst,  portions  of  the  wall  may  be  left  behind  with  safety,  as  experience  has 
shown  that  they  do  not  later  fill  with  cystic  fluid  (Kronig). 

Inasmuch  as  parovarian  cysts  are,  like  tlie  retention  cysts  of  the  ovary, 
benign,  the  prognosis  after  operation  is,  so  far  as  recurrence  goes,  absolutely  good. 

Other  tumors  of  the  parovarium  have  been  described.  Veit  mentions  cases  of  papillary 
cystadenoma,  fibro-adenoma,  adenomyoma,  carcinoma,  adenosarcoma,  and  dermoids  which  are 
described  as  having  developed  in  the  location  of  the  parovarium. 


420  GYNECOLOGY 

TUMORS   OF  THE  TUBES 

CARCINOMA  OF  THE  TUBES 

Primary  carcinoma  of  the  tubes  is  a  relatively  uncommon  disease,  but  is 
found  to  be  somewhat  more  frequent  than  was  formerly  supposed.  In  1910 
only  120  cases  had  been  reported  in  the  literature  (Veit).  Since  then  numerous 
cases  have  been  described. 

The  etiology  of  primary  cancer  of  the  tubes  is  somewhat  interesting  on 
account  of  the  fact  that  at  one  time  it  was  generally  believed  that  the  disease  is 
always  referable  to  a  pre-existing  chronic  inflammatory  process.  At  present 
this  idea  has  been  somewhat  modified,  for,  though  most  cases  are  complicated 
by  chronic  inflammation,  some  have  been  found  in  which  it  is  absent.  It  is  not 
unlikely,  too,  that  the  inflammation  is  sometimes  a  secondary  result  of  the  irri- 
tating influence  of  the  cancer  on  the  surrounding  tissues. 

Most  of  the  reported  cases  have  occurred  after  the  menopause,  between 
the  ages  of  fifty  and  sixty,  but  the  disease  may  appear  earlier,  one  patient 
being  in  her  twenty-seventh  year. 

The  original  seat  of  primary  cancer  of  the  tube  is  in  the  mucous  membrane. 
If  the  disease  appears  in  the  wall  of  the  tube  without  implicating  the  mucosa,  it 
must  be  regarded  as  secondary  to  cancer  of  the  uterus  or  ovary.  One  case  has 
been  described  as  originating  in  an  accessory  tube. 

The  disease  is  usually  unilateral,  occurring  bilaterally  in  about  one-third 
of  the  reported  cases.  It  originates  either  in  the  middle  or  outer  half  of  the 
tube,  the  size  varying  from  that  of  a  pea  to  the  dimensions  of  a  baby's  head. 
The  pathologic  structure  of  the  tumor  is  essentially  papillary,  but  infiltrating 
portions  of  the  carcinomatous  tissue  may  assume  an  alveolar  arrangement. 
When  the  disease  is  in  the  papillary  stage  it  is  difficult  to  distinguish  it  from  the 
benign  papillomata'  that  sometimes  develop  in  the  tubal  canal.  The  general 
microscopic  appearance  of  cancer  of  the  tube  on  account  of  its  papillary  tendency 
closely  resembles  malignant  adenoma  of  the  uterus  and  papillary  adenocarcinoma 
of  the  ovary.  This  is  not  to  be  wondered  at,  as  the  epithelial  cells  of  the 
endometrium,  the  tubal  mucosa,  and  the  germinal  layer  of  the  ovary  have  a 
common  origin.     The  surface  epithelium  in  tubal  cancer  is  not  ciliated. 

The  purely  papillary  form  of  the  disease  is  usually  confined  in  its  growth  to 
the  tube,  but  may  metastasize  to  the  regional  lymph-glands  or  to  distant  parts 
through  the  blood-stream.  The  alveolar  form  has  a  greater  tendency  to  infil- 
trate the  tubal  wall,  and  may  break  through  and  spread  over  the  peritoneum. 
It  may  also  extend  through  the  lymph-channels  to  the  postperitoneal  lymph- 
glands. 

Both  forms  have  a  tendency  to  metastasize  in  the  ovaries  or  uterus. 
Several  cases  of  seed  implantation  have  occurred  following  operation,  one  of 
them  being  in  the  abdominal  scar. 


NEW    GROWTHS  421 

Cancer  of  the  tube  is  difficult  to  diagnose,  most  cases  being  discovered  inci- 
dentally during  operations  for  pelvic  inflammation,  with  which  it  is  usually 
associated.  The  prognosis  is  shown  by  statistics  to  be  unfavorable,  von 
Franque,  in  a  series  of  80  cases  operated  on,  reports  a  permanent  cure  in  only  5. 

The  treatment  of  cancer  of  the  tube  is  very  radical,  the  operation  consisting 
of  removal  of  the  uterus  and  both  adnexa  and  a  search  for  and  dissection  of 
infected  lymph-glands. 

Chorio-epithehoma  may  occur  both  primarily  and  secondarily  in  the  tube. 
(For  further  details  on  this  subject,  see  Chorio-epithelioma.) 

Cancer  of  the  tube  not  infrequently  occurs  secondarily  to  papillary  cancer 
of  the  ovary  or  adenocarcinoma  of  the  body  of  the  uterus.  The  similarity  in 
appearance  of  papillary  tubal  cancer  to  both  these  forms  of  cancer  often  makes 
it  difficult  to  state  in  which  organ  the  disease  was  primary. 

Cancer  of  the  cervix  uteri  rarely  metastasizes  in  the  tube,  only  one  or  two 
cases  having  been  reported.  The  tube  may  take  part  in  a  general  carcinoma- 
tosis of  the  peritoneum,  and  may  also  be  secondarily  infected  from  cancer  of  the 
intestinal  tract. 

OTHER  TUMORS  OF  THE  TUBE 

In  addition  to  cancer  there  are  numerous  other  new  growths  that  occur  in 
the  tubes,  but  all  are  rare.  Mucous  polyps  are  sometimes  seen,  and  are  thought 
to  be  the  occasional  cause  of  extra-uterine  pregnancy.  Papillomata  are  some- 
what more  common.  They  resemble  closely  the  papillary  type  of  tubal  car- 
cinoma, from  which  it  is  difficult  to  distinguish  them. 

Fibromata,  fibromyomata,  and  adenomyomata  occur  as  small  nodules  in  the 
tube,  usually  involving  the  uterine  end  or  the  tubal  isthmus. 

The  true  fibroids  of  the  tube  should  not  be  confounded  with  the  adeno- 
myomata of  the  horns  of  the  uterus,  the  so-called  adenomj^ositis  of  the  horns, 
or  the  related  condition  of  salpingitis  isthmica  nodosa. 

A  few  cases  of  l^inphangiomata  and  dermoid  cysts  of  the  tube  have  been 
described,  and  one  of  so-called  fibromyxoma  cystosum,  the  last  named  probably 
being  of  the  teratoma  group. 

Sarcoma  and  endothelioma  are  rare  tumors  of  the  tube.  Small  cysts  in  the 
subserous  tissue  are  found  attached  to  or  in  the  neighborhood  of  the  tubes, 
most  of  them  probably  representing  retention  cj^sts  of  various  embryonal  rests. 
Of  these,  the  most  common  are  the  so-called  "hydatids  of  Morgagni,"  which 
are  probably  rests  of  the  Wolffian  body.  These  are  small  cysts  filled  with  clear 
serous  fluid  attached  by  long  slender  pedicles  to  the  fimbriae  of  the  tube,  or  to 
the  peritoneum  of  the  mesosalpinx  near  by.  They  do  not  exceed  a  walnut  in 
size  and  have  no  pathologic  significance.  Larger  cysts  have  been  described  as 
originating  in  the  subserous  tissue  of  the  tube  and  occurring  especially  in  con- 
nection with  uterine  fibroids. 


422 


GYNECOLOGY 


Fig.  165. — Adenomtoma  of  the  Tttbe. 
Low  power.     The  tumor  consists  of  gland-like  formations  usually  surrounded  by  connective 
tissue  like  the  stroma  of  the  endometrium  lying  in  the  muscle.     The  gland  on  the  left  shows  this  best. 
The  lumen  of  the  tube  is  obliterated.     These  tumors  occur  in  the  isthmic  portion  of  the  tube  and  are 
often  bilateral. 

TUMORS  OF  THE  ROUND  LIGAMENT 

Round  ligament  tumors  are  comparatively  rare.  The  most  recent  figures 
are  those  of  Taussig,  who  finds  141  cases  reported  in  the  literature.  These 
growths  may  originate  either  in  the  intraperitcneal  part  of  the  ligament  or  in 
that  part  which  hes  in  the  inguinal  canal,  about  75  per  cent,  of  them  springing 
from  the  latter  location.  The  intra-abdominal  tumors  may  grow  from  the 
ligament  with  good  pedicles,  or  they  may  extend  between  the  layers  of  the 
broad  ligament,  for  which  reason  they  are  often  classed  with  tumors  of  the 
pelvic  cellular  tissue.  If  the  tumor  is  situated  near  the  internal  ring  it  may 
grow  subperitoneally. 

Tumors  that  originate  in  the  inguinal  canal  have  a  tendency  to  extend  down 
into  the  vulva.     According  to  Veit,  it  is  probable  that  most  fibroid  tumors 


NEW    GROWTHS  '  423 

of  the  vulva  have  their  origin  in  the  round  hgaments.  Some  tumors  that 
originate  in  the  inguinal  canal  extend  upward  between  the  layers  of  the  ab- 
dominal wall.  One  of  our  cases  developed  in  one  of  the  round  ligament  loops 
that  had  been  attached  in  the  middle  line  in  th©  performance  of  a  Mayo 
internal  Alexander's  operation.  The  histologic  picture  of  the  tumor  was  that 
of  an  adenomyoma,  with  signs  of  chronic  inflammation  in  the  stroma.  In  this 
case  it  seemed  as  if  the  tumor  had  been  excited  by  trauma  or  inflammation, 
and  that  the  process  might  be  properly  classified  as  that  of  an  adenomyositis. 
Most  of  the  round  hgament  tumors  are  small  or  moderate  in  size,  but  they  may 
become  as  large-  as  a  child's  head. 

Histologically,  the  round  hgament  tumors  are  fibromyomatous  in  tj'pe. 
Adenomyomata  are  especially  frequent.  Cystic  and  telangiectatic  changes  are 
common.  A  few  cases  of  mj^osarcoma  have  been  reported  and  one  of  dermoid 
cyst.  The  origin  of  the  adenomyomata  is  thought  by  CuUen  to  be  from  rests 
of  the  ]Mullerian  ducts.     Taussig  beheves  that  they  are  Wolffian  in  origin. 

The  intra-abdominal  tumors  are  slow  growing  and  ordinarily  give  no  sjTup- 
toms  unless  they  become  exceptionally  large.  The  extra-abdominal  growi:hs 
in  the  inguinal  canal  become  noticeable  as  a  Imnp  in  the  groin  and  are  fre- 
cjuently  regarded  as  a  hernia.     They  are  sometimes  associated  with  true  hernias. 

The  treatment  of  round  hgament  tumors  is  removal  if  the}'  give  symptoms 
or  if  they  are  incidentally  encountered  during  a  pelvic  operation. 


TUMORS   OF  THE   PELVIC   CONNECTIVE  TISSUE^ 

Most  of  the  retro-  or  subperitoneal  tumors  of  the  pelvis  have  their  origin 
in  the  connective  tissue  contained  between  the  leaves  of  the  broad  Hgaments. 
Here  can  be  found  numerous  tissue  elements  which  may  serve  as  starting-points 
for  cystic  or  solid  tumors — embryonal  rests,  such  as  the  parovarium  and  Gart- 
ner's ducts,  smooth  muscle-fibers,  hmiph-  and  blood-vessels,  and  the  loose 
cellular  connective  tissue.  In  addition  to  the  tumors  that  grow  primarily  from 
the  subperitoneal  tissue  are  those  that  extend  into  the  intrahgamentary  space 
from  an  original  seat  in  the  uterus  or  ovaries.  Freund  classifies  tumors  of  the 
pelvic  connective  tissue  in  the  following  way: 

I  1.  Fibroma  (fibromyoma). 

T    ,T  ,,  .  .      ^,      \  (a)  Mesodermic  tumors.  {  2.  Sarcoma. 

I.  New   growths   prmiarv   m   the  i  o   t  • 

,   .  ,•,-■'  i  3.  Lipoma, 

pemc  connective  tissue.  i  ,,  >  t^  •  i        ^  ^ 

I  (5)  Dermoid  cvsts. 


II.  New  growths  which  arise  from 
embryonal    elements    in    the  < 
broad  hgaments. 


'  (a)  Parovarial  cysts. 

(b)  Cysts  and  sohd  tumors  of  Gartner's  duct. 

(c)  Dislocated  adrenal  tissue. 

(d)  Cysts  from  rests  of  the  primary  kidney  (Wolffian 

body). 


^Principal  authority,  Freund  (in  Veit,  Vol.  I). 


424  GYNECOLOGY 

III.  New  growths  which  develop  in 


.  ,  ,      .  1  I  (a)  Uterus  (subserous  intrahgamentary  fibroids), 

neighboring    organs    and    ex-  ^  .  tj  +  n 

^      ,  ■   X    XI     1         IT  .  I  (o)  Ovaries  (cysts  or  solid  tuniors). 

tend  into  the  broad  ligaments. 

T^r    AT  _xT-       1  •  1        X      1         ( Carcinoma  of  uterus. 

IV.  New  growths  which  extend  or  i  ^      .  „       ^ 

,     ,     .        ■    ,       XI  1   •     J  Carcinoma  oi  rectum, 

metastasize    into    the    pelvic  S  ^      .  i- 1  i    1 1 

^.      j^.  I  Carcinoma  ot  bladder. 

connective  tissue.  \  ^      ■  r 

\^  Carcinoma  oi  ovaries. 

We  are  at  present  interested  only  in  the  first  group  of  the  classification,  the 
other  groups  having  already  been  discussed  in  their  proper  places. 

The  primary  retroperitoneal  tumors  may  be  located  anywhere  in  the  sub- 
serous cellular  space  that  reaches  from  deep  in  the  pelvis  up  to  the  region  of  the 
kidneys.  Those  that  originate  between  the  free  leaves  of  the  broad  ligament, 
near  the  round  ligaments,  occupy  a  position  in  the  pelvis  similar  to  the  tumors 
of  the  internal  genitalia,  from  which  they  cannot  readily  be  distinguished  by 
bimanual  examination.  Tumors  that  develop  deep  in  the  pelvic  connective 
tissue  usually  grow  downward  in  the  paravaginal  and  pararectal  space,  and  may 
even  extend  through  the  ischiadic  foramen  into  the  gluteal  region.  If  they  have 
their  origin  in  the  tissue  posterior  to  the  cecum  or  sigmoid  flexure,  they  tend  to 
grow  upward  toward  the  kidney  region. 

These  neoplasms  often  attain  an  enormous  size,  and  when  they  develop  in 
certain  situations  in  the  pelvis  cause  extraordinary  dislocations  of  the  pelvic 
organs,  especially  of  the  bladder,  the  vertex  of  which  may  be  forced  high  up  on 
the  abdominal  wall  or  far  to  one  side. 

In  one  case  of  retroperitoneal  sarcoma  that  came  to  the  notice  of  the  author  the  bladder 
was  drawn  out  into  a  spiral  tube  of  such  length  that  the  vertex  could  not  be  reached  by  the  end 
of  a  male  rubber  catheter  inserted  in  the  m-ethra. 

Most  of  these  tumors  grow  slowly  at  first,  and  do  not  cause  sjTuptoms  until 
they  are  large  enough  to  produce  pressure  on  important  organs.  Interference 
with  the  function  of  the  bladder  is  apt  to  be  the  first  sign  of  trouble,  with  reten- 
tion or  incontinence  of  urine.  Pressure  on  the  ureters  maj^  cause  hydronephrosis. 
Freund  describes  a  form  of  "chronic  uremia"  with  general  bodily  disturbances 
consequent  on  the  long  and  slowly  increasing  pressure  interference  of  the  ureters. 
Large  tumors  situated  deep  in  the  pelvis,  especially  those  of  the  solid  type,  in 
the  course  of  time  compress  the  rectum  and  may  completelj^  prevent  the  passage 
of  fecal  matter. 

Interference  with  the  pelvic  circulation  causes  enormous  dilatation  of  the 
veins  and  constitutes  a  serious  danger  to  be  reckoned  with  in  enucleating  the 
tumors. 

Pressure  on  the  nerve  plexuses  of  the  pelvis  sufficient  to  cause  symptoms  is  a 
comparatively  late  development  and  may  produce  pain  of  the  severest  t>"pe. 

Fibromyomata  originate  in  the  smooth  muscle-fibers  with  which  the  broad 
and  round  ligaments  are  abundantly  supplied.     These  tumors,  developing  as 


NEW    GROWTHS 


425 


thej^  do  between  the  leaves  of  the  broad  hgament,  are  to  be  distinguished  from 
the  intrahgamentary  fibroids  of  uterine  origin  by  the  absence  of  myomatous 
tissue  connection  between  them  and  the  uterus.  Uterine  fibroids  that  grow  into 
the  broad  hgament  never  separate  from  the  uterine  wah,  as  do  certain  free 
pedunculated  fibroids  (parasitic  myoma),  so  that  if  there  is  no  myomatous  con- 
nection between  the  hgamentary  fibroid  and  the  uterus  it  must  be  regarded  as 
having  an  independent  origin. 

The  intrahgamentary  fibromyomata  grow  very  slowly,  as  a  rule,  unless  they 
undergo  some  form  of  degeneration,  when  they  may  take  on  a  sudden  and 
rapid  development.  If  they  originate  high  in  the  broad  hgament  they  may 
become  pedunculated.  If  they  start  deeper  in  the  pelvis  they  may  either  extend 
upward  toward  the  region  of  the  cecum  or  sigmoid,  or  downward  toward  the 
ischiadic  foramen. 

Fibromata  of  the  round  ligament  may  develop  intra-  or  extraperitoneally  or 
within  the  inguinal  canal  (Kelly).  The  infundibulopelvic  hgament  may  also 
be  the  seat  of  fibromatous  growi:h. 

Fibroid  tumors  of  the  pehnc  connective  tissue  are  subject  to  the  same  regres- 
sive and  degenerative  changes  characteristic  of  uterine  myomas,  including  com- 
phcations  from  infection,  suppuration,  and  necrosis. 

Sarcoma  of  the  pelvic  connective  tissue  may  start  as  an  essentially  mahgnant 
tumor,  but  more  commonly  it  represents  the  degeneration  of  a  fibroma  or  fibro- 
myoma.  The  sarcomatous  change  in  a  fibroma  is  signified  by  rapid  growi^h  of 
the  tumor  or  by  the  sudden  onset  of  pressure  sjanptoms.  The  prognosis  is  bad, 
for  not  only  is  the  removal  of  the  tumor  difficult  and  dangerous,  but  there  is 
great  probability  of  early  recurrence. 

Lipoma.— Retroperitoneal  lipomata  starting  in  the  connective  tissue  of  the 
pelvis  are  very  rare.  More  common  are  those  that  originate  in  the  mesocolic 
region,  though  these  tumors  may  extend  into  the  pelvic  subserous  tissue.  The 
growi:hs  have  the  form  either  of  pure  hpomatous  or  mjrxomatous  tissue.  They 
grow  diffusely  in  the  subserous  ceUular  tissue  and  may  reach  enormous  dimen- 
sions, reaching  from  the  pelvis  to  the  kidneys.  Some  of  them  undergo  sarcoma- 
tous degeneration  and  recur  after  removal.  Recurrences  also  sometimes  take 
place  after  extirpation  of  tumors  that  are  microscopically  entirely  benign. 

Dermoids.— The  most  interesting  of  the  retroperitoneal  tumors  are  the 
dermoids.  These  originate  in  the  subserous  cellular  tissue  and  are  entirely 
independent  of  the  ovaries,  though  they  possess  the  same  characteristics  of 
structure  as  do  the  ovarian  dermoids.  The  histogenesis  of  extragenital  dermoids 
is  at  present  a  matter  of  speculation,  numerous  theories  having  been  suggested. 
By  the  so-called  blastomere  theory  it  is  thought  that  at  the  earhest  divisions  of 
the  impregnated  egg  one  of  the  original  cell  elements  (blastomere)  becomes 
isolated  and  exists  as  a  fetal  inclusion,  or  as  a  fetus  ^dthin  a  fetus.  Some  regard 
the  tumors  as  springing  from  misplaced  germ-cells  which  develop  partheno- 
genetically,  while  others  believe  that  they  grow  from  accessory  ovarian  tissue. 


426  GYNECOLOGY 

on  the  ground  that   supernumerary  ovaries  with  germ-cells  have  been  found 
within  the  leaves  of  the  broad  ligament;     (See  also  Dermoids  of  the  Ovary.) 

Another  theory  is  that  the  extragenital  dermoids  represent  defective  twin 
development. 

These  cysts  have  a  tendency  to  grow  downward  toward  the  perineum, 
pushing  the  vagina,  uterus,  and  rectum  to  one  side,  and  may  eventually  emerge 
from  the  ischiadic  fossa  in  the  gluteal  region  and  appear  under  the  skin  of  the 
buttocks.  The  size  of  the  tumors  described  varies  from  that  of  a  pigeon's  egg 
up  to  a  baby's  head  (Freund). 

The  cysts  are  usually  oval  in  shape,  though  they  are  so^mewhat  flaccid  and 
adapt  themselves  to  the  compressed  quarters  in  which  they  lie.  The  structure 
of  the  retroperitoneal  dermoids  is,  in  general,  like  that  of  the  dermoids  that 
originate  in  the  ovaries,  except  that  those  which  develop  helow  the  pelvic 
diaphragm  usually  exhibit  the  elements  of  only  one  germinal  layer.  The  con- 
tents usually  consist  of  characteristic  sebaceous  or  atheromatous  material  with 
hair  and  bone,  but  these  may  be  absent  and  the  fluid  may  be  of  a  non-distinctive 
nature. 

The  growth  of  retroperitoneal  dermoids  is  extraordinarily  slow,  and  they 
give  no  symptoms  unless  they  become  infected  or  until  they  become  large 
enough  to  cause  pressure  disturbances. 

The  prognosis  is  good  if  they  can  be  removed  before  they  become  too  large 
or  too  adherent. 

The  treatment  of  retroperitoneal  pelvic  tumors  is  always  surgical  removal 
if  possible,  because  of  the  danger  of  malignant  degeneration  and  the  inevitable 
pressure  disturbances  that  are  sure  to  ensue  sooner  or  later  even  in  the  benign 
growths. 

If  the  tumors  are  large,  their  removal  tests  the  skill  of  the  surgeon  to  the 
utmost.  If  the  tumor  is  attacked  by  the  abdominal  route  an  incision  is  made 
through  the  broad  ligament,  and  then,  at  some  point  that  is  free  of  blood- 
vessels, the  outer  capsule  of  the  tumor  is  divided  and  the  plane  of  cleavage 
is  found.  When  this  plane  has  been  properly  located  the  tumor  can  be  enu- 
cleated gradually  by  blunt  dissection  with  the  fingers.  By  this  method  of  de- 
cortication serious  bleeding  can  be  avoided,  and  there  is  less  danger  of  injuring 
the  rectum  and  bladder.  In  removing  dermoid  cysts  it  is  advisable  to  extir- 
pate them  if  possible  without  rupturing  the  wall,  for  the  contents  are  very 
proteolytic  and  predispose  the  surrounding  tissues  to  infection. 

The  point  of  attack  for  the  cysts  must  be  determined  by  the  location  of  the 
tumor,  and  the  incision  may  be  abdominal,  prevesical,  perineal,  retro-anal, 
or  parasacral. 

TUMORS   OF  THE  BLADDER 

The  most  frequent  and  the  most  important  tumor  of  the  bladder  is  the 
papilloma.     The  majority  of  these  tumors  are  well  pedunculated  and  have  a 


NEW    GROWTHS  427 

characteristic  villous  surface.  Some,  however,  possess  broad  sessile  bases,  while 
the  papillary  nature  of  the  surface  may  be  disguised  by  a  gluing  together 
of  the  villi  from  inflammatory  processes. 

The  papillomata  vary  in  size  from  that  less  than  a  pea  to  that  of  a  man's 
fist.  They  may  be  either  solitary  or  multiple,  or  even  disseminated  over  the 
entire  surface  of  the  bladder  mucous  membrane.  They  occur  most  commonly  on 
the  floor  of  the  bladder,  but  are  not  infrequently  seen  suspended  from  the  vertex. 

The  microscopic  appearance  is  that  of  characteristic  papillary  growth — 
villous  processes  with  a  vascular  connective-tissue  stalk  covered  with  numerous 
layers  of  epithelium,  bespeaking  the  origin  of  the  process  from  the  bladder 
epithelium.  Some  of  the  tumors  are  solid  and  fibrous,  while  others  have  long 
delicate  papillse  like  water  plants.  Incrustations  of  urinary  salts  sometimes 
cover  the  tumor  as  a  result  of  necrosis. 

It  is  often  difficult  to  tell,  even  from  microscopic  examination  of  these 
tumors,  whether  they  are  benign  or  mahgnant.  There  seems  to  be  no  doubt 
that  some  of  the  growths  are  malignant  from  the  beginning,  and  also  that  some 
of  the  papillomata,  though  originating  as  benign  tumors,  later  degenerate  into 
carcinomatous  activity.  It  is  the  part  of  wisdom  to  regard  all  papillomata  of 
the  bladder  as  suspicious,  and  to  remove  them  as  quickly  and  completely  as 
possible. 

CARCINOMA  OF  BLADDER 

Carcinoma  of  the  bladder  occurs  in  the  forms  of  scirrhous,  medullary,  and 
cancroid  squamous  epithelial  growths.  The  scirrhous  variety  is  relatively 
more  favorable  than  the  others.  The  squamous  form  is  said  to  develop  from 
the  leukoplactic  changes  of  a  chronic  cystitis.  Carcinoma  of  the  bladder,  though 
sometimes  at  first  papillary  in  form,  tends  to  spread  out  irregularly  through  the 
wall,  with  ultimate  ulceration  and  infiltration  of  the  paracystic  tissue.  Metas- 
tases are  comparatively  late  and  take  place  in  the  regional  pelvic  lymph-glands. 

Secondary  carcinoma  of  the  bladder  comes  as  a  direct  extension  from  cancer 
of  the  cervix  or  vagina,  but  occurs  later  than  one  would  expect  from  the  close 
proximity  of  the  primarily  diseased  organs.  Invasion  of  the  bladder  wall 
bespeaks  an  advanced  stage  of  cancer  of  the  cervix  or  vagina,  usually  beyond 
the  point  of  operability.  As  the  disease  progresses  the  vesicovaginal  septum 
may  be  eaten  away,  with  consequent  fistula  formation. 

Other  tumors  of  the  bladder  are  of  relative  infrequency.  A  form  of  adenoma 
with  infiltrating  tendencies  has  been  described.  Cases  of  sarcoma  have  been 
reported,  mostly  in  children.  There  have  been  a  few  cases  of  dermoid  cysts 
developing  in  the  wall  of  the  bladder.  These  are  to  be  distinguished  from  the 
ovarian  dermoids  that  occasionally  become  attached  to  and  rupture  into  the 
bladder.  Other  rare  tumors  of  the  bladder  are  myxoma,  fibromyxoma,  and 
fibroma.  Small  cysts  of  the  mucosa  are  the  result  of  chronic  inflammatory 
changes. 


428  GYNECOLOGY 

Symptoms. — The  first  sign  of  a  bladder  tumor  is  usually  bleeding  without 
previous  symptoms,  which  may  suddenly  cease  and  not  appear  again  until 
long  after.  The  bleeding  may  be  shght  or  profuse,  and  may  appear  sponta- 
neously or  as  the  result  of  some  trauma.  It  is  at  first  intermittent,  but  in  the 
course  of  time,  as  the  tumor  grows,  the  hemorrhages  are  more  constant  and  often 
result  in  severe  secondary  anemia. 

The  tumors  are  at  first  uncomplicated  with  cystitis,  but  when  ulceration 
has  occurred,  cystitis,  often  of  a  severe  grade,  ensues. 

The  treatment  of  vesical  tumors  is  immediate  removal.  For  small  single  or 
multiple  papillomata  the  high-frequency  current  is  extremely  efficacious.  For 
the  larger  tumors,  and  those  that  from  their  appearance  suggest  malignancy, 
extirpation  by  the  suprapubic  route  is  the  best  course.  For  the  more  extensive 
growths,  where  greater  exposure  of  the  bladder  is  required,  the  transperitoneal 
route  is  available  and  comparatively  safe. 

Total  extirpation  of  the  bladder,  with  implantation  of  the  ureters  in  the 
bowel,  is  an  operation  of  last  resort.  The  mortality  of  this  operation  is  high, 
while  an  ascending  infection  of  the  ureters  and  kidneys  is  almost  inevitable. 

VESICAL  CALCULUS 

Stone  in  the  bladder  is  far  less  common  in  women  than  in  men  partly  be- 
cause the  exciting  causes,  so  far  as  they  relate  to  cystitis,  are  more  easily  healed 
in  women,  and  partly  because  the  female  urethra  more  readily  allows  the  pass- 
age of  small  vesical  or  renal  concretions  before  they  have  a  chance  to  reach  a 
size  of  clinical  importance. 

Vesical  calculi  form  by  the  crystallization  of  different  urinary  salts,  and 
may  originate  in  the  bladder  itself  or  be  passed  into  the  bladder  from  the  kidney. 
They  are  composed  chiefly  of  ammonium  urates,  phosphates,  uric  acid,  oxalates, 
carbonates,  cystin,  and  xanthin,  the  larger  stones  having  usually  a  mixed  com- 
position, which  gives  them  a  distinct  lamellated  structure. 

The  primary  etiologic  factor  in  the  formation  of  urinary  calculi  is  thought  to 
be  some  obstruction  or  stagnation  of  the  urine.  Cystitis  and  ammoniacal 
conditions  are  especially  favorable.  Concretions  always  form  about  foreign 
bodies  which  are  not  infrequently  found  in  the  bladder  of  women.  These 
consist  of  small  objects,  such  as  hair-pins,  pencils,  nails,  etc.,  which,  being 
used  for  purposes  of  abortion  or  masturbation,  accidentally  slip  through  the 
urethra  into  the  bladder.  Other  foreign  bodies  that-  are  found  in  the  bladder 
as  nuclei  of  calcuH  are  pieces  of  cotton,  broken  bits  of  catheter,  or  other  instru- 
ments used  by  physicians  in  treatment.  One  of  the  commonest  starting-points 
for  a  concretion  is  the  so-called  "wandering"  stitch  or  unabsorbable  hgature 
that  has  been  placed  in  the  bladder  wall  during  a  previous  pelvic  operation. 

The  real  vesical  calculi  move  freely  in  the  bladder  unless  they  are  impacted 
in  diverticula,  a  favorite  location,  or  are  fixed  in  the  urethral  canal.     They 


NEW    GROWTHS  429 

may  exist  for  a  considerable  period  without  causing  symptoms,  but  erosion  of 
the  wall,  with  bleeding  and  subsequent  infection,  are  sure  to  take  place  in  time. 
The  symptoms,  then,  are  of  a  severe  cystitis  with  hematuria. 

The  diagnosis  is  not  usually  difficult.  Many  times  the  stone  can  be  felt 
by  bimanual  examination,  while  a  sound  will  give  the  characteristic  metalhc 
click  unless  the  stone  is  so  embedded  that  the  instrument  cannot  come  in 
contact  with  it.  The  diagnosis  is  established  by  the  cystoscope  and  by  the 
a;-ray. 

Treatment. — Small  stones  and  foreign  bodies  can  be  drawn  out  through  the 
urethra  with  the  help  of  the  cystoscope,  but  great  care  should  be  taken  not  to 
injure  the  vesical  sphincter  or  lacerate  the  urethral  mucous  membrane.  By 
means  of  the  lithotrite,  a  powerful  crushing  instrument,  many  stones  can  be 
broken  and  removed  piece  by  piece,  or  crushed,  and  the  small  bits  washed  out 
of  the  bladder  by  an  irrigating  and  evacuating  apparatus.  If  the  stone  is  so 
large  or  hard  that  these  means  are  not  feasible,  it  can  be  removed  through  a 
vesicovaginal  opening,  the  wound  being  left  open  for  drainage  if  there  is  present 
a  severe  cystitis.  A  large  stone  may  also  be  removed  through  a  suprapubic 
extraperitoneal  incision. 

TUMORS   OF  THE   RECTUM 

CANCER  OF  THE  RECTUM 

Of  the  malignant  growths  of  the  rectum,  carcinoma  is  by  far  the  most  com- 
mon. The  tj^pe  of  cancer  most  frequently  found  is  the  adenocarcinoma,  which 
repeats  in  its  structure  the  rectal  mucous  membrane  from  which  it  is  sometimes 
difficult  to  distinguish  it,  excepting  by  its  tendency  to  penetrate  into  the  deeper 
layers  of  the  rectal  wall.  Colloid  carcinomata,  and  occasionally  the  medullary 
and  scirrhous  types,  may  also  occur.  They  grow  most  commonly  at  the  lower 
end  of  the  gut,  just  within  the  anus  or  at  the  junction  of  the  rectum  with  the 
sigmoid,  though  they  may  originate  at  any  point  of  the  rectal  canal.  Consti- 
tuting as  they  do  pelvic  tumors  which  can  be  palpated  by  vagina,  they  come,  to  a 
certain  extent,  within  the  sphere  of  gynecology.  They  may  occupy  only  limited 
portions  of  the  rectal  wall  or  they  may  extend  around  the  entire  circumference 
of  the  tube  in  the  manner  of  the  inflammatory  strictures  (g.  v.).  They  metas- 
tasize to  the  regional  lymph-glands,  and  may  spread  by  direct  extension  to 
various  parts  of  the  pelvis  involving  the  pelvic  connective  tissue.  Extension 
into  the  vaginal  mucous  membrane  sometimes  takes  place.  In  the  later  stages 
distant  metastases  are  sent  to  the  liver  and  lungs. 

Sjmiptoms. — The  chief  symptom  of  cancer  of  the  rectum  is  bleeding,  due  to 
the  tendency  which  the  tumor  has  of  superficial  necrosis  and  ulceration.  Rec- 
tal pain  is  a  comparatively  early  symptom.  There  is  also  a  marked  tendency 
to  constrict  the  bowel,  especially  in  the  annular  form,  with  dilatation  of  the 


430 


GYNECOLOGY 


bowel  above  and  retention  of  feces  and  the  products  of  necrosis  of  the  tumor. 
This  results  in  severe  auto-intoxication  and  cachexia. 

The  diagnosis  of  cancer  of  the  rectum  is  not  difficult.  In  most  cases  the 
tumor  mass  can  be  felt  both  by  vaginal  and  rectal  examination  and  can  be 
seen,  through  the  proctoscope.  With  the  aid  of  a  proctoscope,  if  the  tumor  is 
not  situated  too  high,  a  specimen  can  be  removed  for  microscopic  examination. 
A  differential  diagnosis  between  inflammatory  stricture  and  the  annular  form  of 
carcinoma  may  be  quite  difficult.  In  this  the  general  constitutional  symptoms 
are  often  of  assistance,  for,  as  a  rule,  the  general  effect,  of  inflammatory  stricture 
on  the  health  of  the  patient  is  much  less  severe  than  that  from  cancer. 

The  prognosis  of  cancer  of  the  rectum  is,  in  general,  rather  bad,  but  it  is- 
much  better  in  women  than  in  man,  due  to  the  fact  that  the  rectum  is  less  adher- 
ent in  the  female  pelvis,  and  hence  offers  a  better  chance  for  surgical  removal 
of  the  disease. 

The  treatment  of  cancer  of  the  rectum  is  radical  removal  if  the  disease  is  not 
too  far  advanced.  Eadium  seems  to  be  less  efficacious,  in  this  disease  than  in 
cancer  of  the  cervix.  The  nature  of  the  operation  depends  on  the  location  of 
the  tumor  mass.  An  early  cancer  situated  just  above  the  anus,  which  has  not 
penetrated  the  deeper  layers,  can  sometimes  be  removed  through  a  dilated 
sphincter  by  resecting  the  gut  in  the  manner  of  Whitehead's  operation  and 
suturing  the  upper  end  to  the  anal  membrane.  Cases  as  favorable  as  this  are- 
not  often  seen.  Low  cancer  of  the  rectum  may  sometimes  be  removed  through; 
an  incision  starting  from  the  vagina  through  the  perineum  and  into  the  sphincter 
muscle.  If  necessary  the  sphincter  may  be  cut  both  anteriorly  and  poste- 
riorly, and  the  incision  carried  back  to  the  coccyx  (Abbe).  The  rectum  can 
then  be  dissected  out,  including,  if  necessary,  some  of  the  vaginal  wall.  In  this 
way  several  inches  of  the  gut  may  be  resected  and  the  upper  end  brought  down 
and  sutured  to  the  anus.  The  cut  ends  of  the  sphincter  are  sutured  and  the 
wound  of  the  perineum  and  vagina  closed  by  the  usual  plastic  methods.  In 
this  way  control  of  the  bowels  is  maintained.  Abbe  recommeneds  an  inguinal- 
colostomy  as  a  preliminary  to  this  operation.  Only  a  few  cases  are  seen  which 
are  early  enough  for  a  cure  by  this  method.  Occasionally  a  cancer  of  the 
rectum  near  the  junction  of  the  sigmoid  can  be  resected  and  the  bowel  ends 
united  by  end-to-end  anastomosis.  The  author  has  one  such  case  well  at  the 
end  of  five  years.  For  the  extensive  cases  more  radical  measures  are  necessary. 
These  include  the  establishment  of  an  artificial  anus  and  a  dissection  of  the  rec- 
tum either  by  the  abdominal  or  perineal  route,  or  by  a  combination  of  both,  or 
by  the  removal  of  the  sacrum  according  to  the  method  recommended  b}^  Kraske. 

Other  malignant  tumors  of  the  rectum  are  epitheliomata  which  grow 
inward  from  the  anal  region,  sarcomata,  and  endotheliomata,  all  of  which, 
are  rare  tumors. 

The  treatment  of  these  tumors  is  the  same  as  that  for  cancer. 


NEW    GROWTHS  431 


ADENOMA 


Adenomata  of  the  rectum  are  benign  new  growths  springing  from  the  rectal 
mucous  membrane.  They  may  be  sessile  or  pedunculated,  in  which  latter  case 
they  constitute  the  familiar  rectal  polypi,  the  most  common  of  benign  tumors 
of  the  rectum.  These  pol^^pi  may  be  single  or  multiple,  and  sometimes  occur 
in  such  numbers  and  are  so  closely  grouped  that  the  term  "polyposis"  has  been 
applied  to  the  condition.  The  rectal  polyp  repeats  histologically  the  rectal 
mucous  membrane  from  which  it  originates,  except  that  there  is  usually  a 
marked  hyperplasia  of  the  glandular  structure  which  occasionally  becomes 
cystic.  Rectal  polypi  vary  in  size  from  that  of  a  pea  to  a  walnut,  and  tend,  as 
a  rule,  to  remain  benign  in  character.  They  are,  however,  sometimes  the  start- 
ing-point for  adenocarcinoma. 

Some  of  the  rectal  polypi  are  fibrous  in  structure  and  represent  probably  a 
growth  from  the  rectal  submucosa. 

The  polypoid  growths  of  the  rectum  cause  bleeding  and  sometimes  tenes- 
mus. They  are  diagnosed  without  difficulty  and  are  best  treated  by  surgical 
removal.  The  rare  condition  of  polyposis  is  a  grave  disease,  the  treatment  of 
which  must  be  determined  by  the  exigencies  of  the  case. 

PROLAPSE  OF  THE  RECTUM 

Prolapse  of  the  rectum  is  a  disease  that  occurs  most  frequently  in  child- 
hood, but  is  sometimes  seen  in  the  adult.  True  prolapse  of  the  rectum  must  be 
distinguished  from  prolapse  of  the  mucous  membrane,  which  is  a  common  accom- 
paniment of  hemorrhoids.  In  the  latter  case,  the  mucous  membrane  slips  away 
from  its  loose  attachment  to  the  muscular  layer  of  the  rectal  wall  and  protrudes 
from  the  anal  orifice.  The  extent  of  prolapse  of  this  kind  is  necessarily  limited, 
seldom  more  than  1  inch  of  the  rectal  mucosa  coming  down.  This  form  of  pro- 
lapse has  been  termed  "incomplete  prolapse"  and  "prolapsus  ani."  It  may 
sometimes  be  the  preliminary  stage  of  a  later  true  prolapse  of  the  rectum. 

Prolapse  of  the  rectum,  in  its  strictest  sense,  relates  to  a  turning  inside 
out  of  the  entire  rectum,  including  all  the  layers  of  the  wall.  The  descent  of 
the  rectum  is  due  to  a  loss  of  the  somewhat  loose  connective-tissue  attachment 
which  it  has  to  the  hollow  of  the  sacrum.  In  children,  the  curve  of  the  sacrum 
being  flatter  than  in  the  adult  and  the  sacral  attachment  being  more  delicate, 
prolapse  after  prolonged  straining  or  depleting  diseases  is  comparatively  com- 
mon. In  the  adult,  on  the  other  hand,  the  more  pronounced  curve  of  the 
pelvic  outlet  and  the  greater  development  of  the  protecting  levator  ani  muscles 
makes  the  disease  uncommon.  In  gynecologic  practice  the  condition  may  be 
seen  at  any  age,  but  it  is  said  to  be  more  common  in  elderly  women  in  whom 
there  is  much  perineal  and  sphincteric  relaxation.  Most  of  the  cases  we  have 
aeen  have  been  in  comparatively  young  women. 


432  GYNECOLOGY 

The  characteristic  appearance  of  prolapse  of  the  rectum  is  that  of  a  rosette 
which  extrudes  with  the  act  of  defecation.  The  size  of  the  extruded  mass  is, 
as  a  rule,  surprisingly  large.  It  is  usually  not  painful  at  first,  but,  as  the  pro- 
lapse recurs  more  and  more  frequently  and  drying  and  ulceration  of  the  mucous 
membrane  takes  place,  the  condition  may  become  very  distressing.  In  the 
more  advanced  cases  there  is  frequently  a  hernia  of  Douglas'  pouch,  contain- 
ing intestines  situated  in  the  anterior  part  of  the  prolapsed  mass.  This,  as  Mos- 
chowitz  has  pointed  out,  represents  the  type  of  "sliding  hernia." 

The  treatment  should  always  at  first  be  palliative  and  supportive.  Opera- 
tion is  rarely  necessary  in  children,  a  cure  being  usually  possible  by  so  strapping 
the  buttocks  as  to  prevent  extrusion  and  at  the  same  time  allow  for  defeca- 
tion. In  the  adult  the  same  procedure  can  be  carried  out  unless  there  is  great 
relaxation  of  the  parts  surrounding  the  anus. 

Some  advocate  the  use  of  a  vulcanite  plug  held  in  place  by  a  T-bandage  and 
pad,  and  claim  by  this  method  that  in  time  the  natural  tonicity  of  the  support- 
ing structures  asserts  itself  sufficiently  to  maintain  the  rectum  in  position. 
Cold  and  mildly  astringent  enemas  may  be  tried  at  first. 

If  the  case  is  intractable,  one  must  resort  to  surgical  methods,  which  consist 
either  of  linear  cauterization  or  of  various  cutting  operations.  Linear  cauteriza- 
tion, performed  under  anesthesia,  is  done  by  drawing  several  times  a  blunt- 
pointed  PaqueHn  cautery  at  dull  red  heat  along  the  mucous  membrane  in  the 
longitudinal  axis.  The  cautery  should  sere  only  the  mucous  membrane  and  not 
be  allowed  to  burn  deeply  into  the  muscular  tissue.  Five  or  six  lines  should  be 
made.  This  procedure  sets  up  an  inflammatory  reaction,  which  after  healing 
serves  to  prevent  the  descensus  of  the  bowel.  This  method  can  also  be  used  for 
prolapse  of  the  rectal  mucous  membrane. 

The  surgical  operations  best  adapted  to  the  cure  of  prolapse  are  described 
in  detail  in  the  section  on  Operative  Technic.  They  consist  of  amputation  of 
the  prolapsed  rectum,  fixation  of  the  rectum  to  the  sacrum,  and  intra-abdominal 
suspension. 

HEMORRHOIDS 

Hemorrhoids  constitute  a  varicose  condition  of  the  hemorrhoidal  veins. 
They  have  been  classified  as  to  form,  location,  and  consistency  in  numerous 
different  ways,  but  the  description  by  Pennington  is  especially  practical.  He 
calls  attention  to  the  fact  that  hemorrhoids  are  formed  on  the  inner  side  of  the 
two  cones  that  coalesce  in  embryonal  fife  to  form  the  anal  canal.  The  upper 
cone  represents  the  end  of  the  hindgut  (rectum),  and  is  lined  with  intestinal 
mucous  membrane  and  nourished  by  the  superior  hemorrhoidal  vessels.  The 
lower  cone  is  the  proctodeum  and  corresponds  to  the  anal  dimple  (Fig.  166). 
It  is  lined  with  squamous  epithelium  and  is  supplied  by  the  inferior  hemorrhoidal 
vessels.  In  embryonal  life  the  apices  of  these  two  cones  unite  at  the  pectinate 
line,  failure  of  union  being  the  cause  of  imperforate  anus.     Pennington  dis- 


NEW    GROWTHS 


433 


tinguishes  hemorrhoids  according  to  their  location  in  relation  to  the  point  of 
coalescence  of  the  two  cones.  Internal  hemorrhoids  represent  a  dilatation  of 
the  superior  hemorrhoidal  veins  in  the  upper  cone,  while  external  hemor- 
rhoids result  from  distention  of  the  inferior  hemorrhoidal  veins  of  the  lower 
cone.  Interno-external  hemorrhoids  are  located  partly  within  both  cones,  and 
are  the  result  of  a  varicose  condition  of  both  superior  and  inferior  sets  of  veins. 
Internal  hemorrhoids  always  contain  fluid  blood,  the  interno-external  type 
contain  both  fluid  and  clotted  blood,  while  the  external  hemorrhoid  either  con- 
tains a  clot  (thrombotic  pile)  or  is  a  mere  tab  of  skin  which  represents  the  rem- 
nant of  an  old  hemorrhoid. 


XcmotrVvoib 


txVemcu 
Me.>rY\ovr\vo\b 


Fig.  166. — Hemorrhoids. 
The  three  types  of  hemorrhoids  are  shown — internal,  external,  and  interno-external. 

Pennington.) 


(After 


The  causes  of  piles  are  extraordinarily  numerous.  Some  individuals  in- 
herit a  predisposition  to  piles  in  a  congenital  deficiency  in  the  supporting  power 
of  their  tissues.  Very  important  are  those  conditions  which  cause  stasis  or  ob- 
struction of  the  portal  system,  in  which  a  long  column  of  blood  is  unsupported 
by  valves.  The  pregnant  uterus  and  tumors  that  exert  pressure  on  the  mesen- 
teric vessels  or  some  part  of  the  portal  system  are  examples.  Abdominal  pressure 
exerts  an  obstructing  influence  on  the  portal  circulation,  and,  therefore,  the 
labors  of  childbirth  constitute  a  frequent  cause  of  hemorrhoids  which,  how- 
ever, may  exist  only  temporarily.  Chronic  diseases  of  the  heart,  lungs,  and 
liver  are  frequently  associated  with  hemorrhoids.     Chronic  constipation  and 

28 


434  GYNECOLOGY 

enteroptosis  are  other  factors.  Retroversion  of  the  uterus  and  pressure  on  the 
rectum  by  pelvic  tumors  are  usually  mentioned  in  the  etiology,  but  probably 
do  not  play  a  very  important  role. 

A  very  frequent  cause  of  hemorrhoids,  not  always  sufficiently  appreciated, 
is  the  lacerated  or  relaxed  perineum.  Here  the  support  of  the  levator  ani 
muscles,  which  is  of  importance  to  the  proper  circulation  of  the  anal  region,  is 
lost  or  made  incomplete  by  the  separation  and  retraction  of  the  two  muscles. 
The  importance  of  the  relaxed  perineum  in  the  causation  of  hemorrhoids  is  evi- 
denced by  the  regularity  with  which  hemorrhoidal  symptoms  are  relieved 
following  perineoplastic  operations. 

External  hemorrhoids  become  inflamed  easily,  in  which  case  they  are  swollen 
and  edematous  and  are  very  painful.  Itching  is  sometimes  a  distressing  sjnnp- 
tom.  In  individuals  with  little  resistance  the  inflammation  may  be  extensive 
and  even  involve  the  veins  of  the  leg.  Skin-tabs  do  not  ordinarily  give  much 
discomfort,  but  they  are  liable  to  recurrences  of  thrombosis  or  inflammation. 
Internal  hemorrhoids  are  liable  to  fissure  and  especially  to  bleeding.  The 
bleeding  may  be  only  slight  in  amount  and  give  little  trouble,  or  it  may  be 
serious  enough  to  cause  grave  anemia  or  even  fatal  hemorrhages. 

The  diagnosis  of  external  hemorrhoids  is  a  simple  matter.  For  internal 
hemorrhoids  a  digital  examination  should  always  be  made,  to  I'ule  out  the 
possibility  of  stricture,  cancer,  or  ulceration  of  the  rectum.  Internal  hemor- 
rhoids cannot  easily  be  felt  by  the  examining  finger  and  should  be  subjected  to 
inspection.  This  can  best  be  done  by  placing  the  patient  in  the  Sims  position. 
With  the  right  forefinger  hooked  into  the  perineum,  and  pressing  strongly  on  the 
rectal  wall  toward  the  anus,  the  entire  anal  canal  is  easily  rolled  out  and  com- 
pletely exposed  to  view.  The  maneuver  is  more  successful  if  the  patient  at  the 
same  time  exerts  abdominal  pressure  as  in  the  act  of  defecation. 

The  treatment  of  hemorrhoids  comprises  palliative  and  operative  measures. 
Palliative  treatment  does  not  effect  a  cure,  but  serves  to  alleviate  distressing 
symptoms  during  an  "attack." 

A  restricted  diet  and  the  use  of  cathartics  that  produce  soft  unirritating 
stools  are  of  first  importance.  Local  applications  in  the  form  of  ointments 
(Ung.  gallse  et  opii,  hamamelis,  etc.)  are  useful  if  the  ointment  is  applied  so  that 
it  comes  in  contact  with  the  mucous  surface  inside  the  sphincter.  Hamamelis 
suppositories  are  excellent  for  the  average  case.  Inflamed  piles  are  best  treated 
by  rest  and  hot  fomentations,  frequently  changed  and  held  snugly  against  the 
anus  by  a  T-bandage.  Morphin  suppositories  may  be  necessary  for  the  pain 
in  severe  cases.  Strangulated  piles  must  be  reduced,  if  necessary  under  an  anes- 
thetic. 

In  considering  radical  treatment  for  hemorrhoids  it  must  be  remembered 
that  operations  for  this  disease  are  not  without  their  drawbacks.  Dangerous 
hemorrhage,  sepsis,  even  fatal  embolism  have  been  known  to  occur.  If  the 
operation   is   done  coincidently  with  an  abdominal  section  the  convalescence 


NEW    GROWTHS 


435 


may  be  greatly  complicated  by  the  inability  to  use  the  rectum  for  enemata  if 
there  is  stasis  of  the  bowels. 

The  mere  existence  of  hemorrhoids  does  not  indicate  an  operation.  Con- 
tinued symptoms  do.  In  the  case  of  hemorrhoids  dependent  on  perineal  relaxa- 
tion the  plastic  operation  usually  cures  the  hemorrhoids. 

The  methods  of  operating  on  hemorrhoids  are  numerous,  and  may  be  divided 
in  two  classes:  (1)  Those  that  depend  for  their  efficacy  on  the  creation  of  a 
slough  and  heahng  by  granulation,  and  (2)  those  that  depend  on  clean  removal. 
In  the  first  class  are  included  such  procedures  as  crushing,  apphcation  of  strong 
nitric  acid,  injections  of  carbohc  acid,  and  the  classical  clamp  and  cautery. 
Operations  of  the  second  class  include  dissection,  hgature,  and  the  annular 
excision  commonly  known  as  Whitehead's  operation. 

Operations  of  the  first  class  are  rarely  used  now,  as  they  have  fittle  to  recom- 
mend them.  They  are  apt  to  be  followed  by  bleeding,  swelling,  and  fissures. 
Operations  of  the  second  class  are  described  in  the  section  on  Operative  Technic 
(see  page  819),  and  are  the  procedures  of  choice. 


Defects  of  development 

Embryologic  Development  of  the  Genital  Organs. — A  knowledge  of  the  main 
processes  that  take  place  in  the  fetal  development  of  the  pelvic  organs  is  neces- 
sary for  an  understanding  of  certain  malformations  and  tumor  groT\i:hs. 

At  about  the  end  of  the  fourth  week  of  embryonal  hfe  in  the  human  the 
Wolffian  bodies  are  formed  along  the  sides  in  the  lower  third  of  the  body,  reach- 
ing upward  as  far  as  the  point  where  later  the  diaphragm  develops  and  extend- 
ing downward  in  the  form  of  a  duct  (Wolffian  duct)  to  the  cloaca. 

In  the  fifth  to  the  sixth  week  of  embryonal  hfe  there  appear,  just  inside  of 
the  Wolffian  bodies,  the  elements  of  the  genital  glands,  covered  with  a  special 
epithehal  layer,  the  so-called  "germinal  epithehum,"  which  contains  here  and 
there  cells  rich  in  protoplasm,  the  primary  eggs. 

Coincidently  with  the  development  of  the  genital  glands  there  are  seen, 
situated  externally  to  the  Wolffian  bodies,  two  ducts  which  extend  to  the  uro- 
genital sinus  (Fig.  167).  These  are  the  ]\Iullerian  ducts.  From  the  primary 
genital  glands  are  developed  the  ovaries  in  woman,  while  from  the  Miillerian 
ducts  is  developed  the  entire  genital  tract  to  the  vaginal  introitus. 

The  Mullerian  ducts  are  at  first  sohd,  and  extend  to  the  urogenital  sinus  as 
separate,  unfused  structures.  Malformations  of  the  genital  tract  always  imply 
some  disturbance  in  the  proper  development  of  these  two  ducts,  and  involve 
either  an  atresia  of  one  or  both  ducts  or  a  lack  of  fusion.  If  the  development 
of  Miiller's  ducts  proceeds  normally  they  run  close  together  in  their  lower  half, 
eventual^  becoming  merged  into  one  structure.  The  upper  parts  of  this 
structure  (the  future  uterus)  first  acquire  lumens  lined  with  a  single  laj^er  of 
cyhnder  epithelium,  while  the  lower  section  of  the  fused  portion  (the  future 
vagina)  remains  solid  for  a  somewhat  longer  period,  being  composed  of  large 
cells  rich  in  protoplasm.  Gradually,  however,  this  lower  part  also  acquires  a 
lumen  and  becomes  the  vagina.  The  fusion  of  the  lower  half  of  Miifier's  ducts 
is  completed  in  the  ninth  fetal  week.  At  this  period  the  vagina  is  merged  into  a 
single  structure,  but  is  still  solid.  The  uterus,  on  the  other  hand,  is  separated 
into  two  hollow  comipartments,  this  double  construction  remaining  until  the 
fourth  or  fifth  month,  when  the  uterus  and  vagina  acquire  a  single  communi- 
cating lumen,  which  shows  no  signs  of  the  former  double  formation,  except  a 
slight  depression  at  the  fundus  where  the  partition  ended.  It  is  important  to 
keep  clearly  in  mind  tliis  particular  part  of  the  embr3"olog5''  of  the  genital  tract 
in  order  to  comprehend  the  various  types  of  maldevelopment  of  the  uterus. 

At  about  the  beginning  of  the  fifth  month  the  uterus  becomes  differentiated 
from  the  vagina  by  the  formation  of  the  vaginal  portion  (cervix).     At  the  end 

436 


DEFECTS    OF    DEVELOPMENT 


437 


of  the  fifth  month  the  fundus  of  the  uterus  rounds  out,  so  that  all  appearance  of 
the  former  double  character  of  the  uterine  body  disappears.  The  wall  of  the 
uterus  acquires  muscle-fibers  at  about  the  fifth  month,  at  which  time  also  the 
hymen  appears  as  a  special  differentiation  of  the  lower  vaginal  segment.  At 
birth  the  uterine  body  is  small,  thin  walled,  and  insignificant  in  comparison 
with  the  cervix. 


oC  Houtt 


N<><:?.c^ 


Fig.  167. — Diagram  Showing  the  Relationship  of  the  Mullerian  and  Wolffian  Ducts  and 
THEIR  Openings  into  the  Urogenital  Sinus. 


Even  in  the  earliest  periods  can  be  noted  a  difference  in  the  character  of  the 
epithelium  in  different  segments  of  the  Mtillerian  ducts.  The  upper  portions 
from  which  the  tubes  and  uterus  are  formed  first  become  hollow,  and  are  lined 
with  a  simple  cylinder  epithelium,  while  the  vaginal  part,  as  was  stated  above, 
remains  until  a  later  period  a  solid  structure,  filled  with  large  cuboidal  epithelial 
cells.  The  layer  of  epithelium  which  lines  the  upper  parts  does  not  become 
ciliated  until  extra-uterine  life. 

The  mucous  membrane  of  the  uterine  body  is  in  the  embryo  very  little 


438 


GYNECOLOGY 


differentiated  from  that  of  the  cervix,  while  the  branching  folds,  which  charac- 
terize the  cervix  in  the  adult  (arbor  vitse),  are,  in  the  embryo  and  child,  con- 
tinued to  the  fundus  of  the  uterus  (Fig.  168).  The  establishment  of  secreting 
glands  in  the  mucosa  of  the  uterus  is  a  late  development,  there  being  no  definite 
period  for  their  appearance.  It  is  said  that  in  some  instances  there  is  a  full 
equipment  of  glands  at  birth,  while  in  others  they  do  not  appear  until  the  child 
is  ten  or  twelve  years  old.     The  glands  of  the  cervix  develop  first. 


^r^iyy 


i  4 

Fig.  168. — Development  of  the  Utebus.' 
1.  Uterus  of  newborn  child.  The  cervix  shows  much  greater  development  than  the  body.  The 
folds  of  the  arbor  vitae  reach  from  the  cervix  to  the  top  of  the  uterine  canal.  2.  Uterus  of  a  seven- 
year-old  child.  The  body  is  equal  in  development  to  that  of  the  cervix.  The  folds  of  the  arbor  vitae 
reach  just  beyond  the  internal  os.  3.  Uterus  of  a  mature  virgin.  The  development  of  the  body 
excels  that  of  the  cervix.  The  folds  of  the  arbor  vitse  reach  only  to  the  internal  os.  4.  Uterus  of  a 
woman  who  has  borne  children.  The  body  shows  a  still  greater  development.  The  folds  of  the 
arbor  vitse  occupy  only  about  two-thirds  of  the  cervical  canal.  The  external  os  of  the  cer\Tx  is  dilated, 
(vyter  Kiistner.) 

As  the  Miillerian  ducts  develop  in  the  female  there  is  a  corresponding  retro- 
gression of  the  Wolffian  ducts,  remnants  of  which  may  later  play  a  part  in  the 
formation  of  certain  pelvic  tumors. 

Retrogression  of  the  Wolffian  body  and  ducts  begins  at  the  seventh  or  eighth 
week  and  is  completed  about  the  fifteenth  to  the  sixteenth  week  of  fetal  life. 
Rests  of  these  structures  persist  in  the  broad  hgament  under  the  name  of  the 


DEFECTS    OF    DEVELOPMENT  439 

''parovarium,"  which  appears  in  the  form  of  a  comb,  with  the  back  running 
parallel  with  the  tube,  and  the  teeth  extending  in  a  somewhat  radiating  direc- 
tion toward  the  ovary.  The  parovarium  is  divided  into  two  parts,  the  outer 
(or,  more  exactly,  the  upper)  part,  near  the  tubal  extremity,  being  termed  the 
epoophoron,  and  the  inner  (or  lower)  part,  near  the  round  ligament,  the  paro- 
ophoron. The  thread-like  strands  of  the  parovarium  are,  in  reality,  minute 
canals  lined  with  a  low  cuboidal  epithelium  and  surrounded  with  a  firm  con- 
nective tissue  (Schuler).  In  the  paroophoron  portion  are  sometimes  found 
rudimentary  glomei-uli.  The  small  pedunculated  hydatid  cj^sts  of  JNIorgagni, 
often  seen  dangling  from  the  edge  of  the  broad  ligament  near  the  fimbriae,  are 
regarded  as  remnants  of  this  Wolffian  body. 

The  back  of  the  comb-like  figure,  by  which  we  have  described  the  paro- 
varium, represents  the  remains  of  the  Wolffian  duct.  This  duct  may  persist 
in  a  part  or  the  whole  of  its  course.  Thus,  there  is  sometimes  a  communicating 
tubule  between  the  epoophoron  and  the  edge  of  the  broad  ligament  in  the 
fimbriae.  That  part  below  the  parovarium  is  sometimes  also  found  to  persist, 
and  to  it  has  been  given  the  name  "Gartner's  duct."  As  a  rule,  only  short 
segments  of  this  duct  persist,  but  in  a  few  instances  it  has  been  traced  from  the 
parovarium  to  the  uterus,  through  the  uterine  musculature  to  the  vaginal  por- 
tion, and  through  the  vaginal  wall  to  an  opening  at  the  hymen.  The  course  in 
the  vagina  is  along  the  lateral  or  dorsal  part  of  the  wall. 

The  persisting  rests  of  Gartner's  duct  maj^  be  the  seat  of  retention  cysts 
or  of  epithelial  new  growths. 

Ovaries. — To  the  median  side  of  Aliiller's  ducts  and  the  Wolffian  body  appear 
at  about  the  sixth  week  the  rudiments  of  the  genital  glands,  which  in  the  male 
develop  into  testicles  and  in  the  female  into  ovaries.  These  structures  are  at 
first  alike  in  both  sexes,  and  consist  of  a  connective-tissue  ridge  covered  with 
cylinder  epithelium.  Differentiation  into  the  male  or  female  organ  takes 
place  in  the  next  three  months.  The  development  of  the  ovary  is  characterized 
by  a  rich  proliferation  of  cells  from  the  epithelial  covering  (germinal  epithelium), 
together  with  an  ingrowth  of  connective-tissue  cells  and  blood-vessels  from  the 
neighboring  Wolffian  ]x)dy.  The  epithelial  cells  which  permeate  the  structure 
become  cut  off  and  confined  in  balls  or  compartments  (Eifacher  of  Nagel,  Eibal- 
len  of  Waldej^er),  and  form  the  basis  for  the  primordial  follicles. 

The  folHcles  first  formed  retreat  toward  the  center  of  the  organ,  while  new 
folficles  are  formed  from  the  surrounding  germinal  epithelium  which  has  a 
tendency  to  dip  inward  into  the  stroma  (Fig.  8). 

A  remnant  of  this  process  can  be  seen  in  the  newborn  in  the  form  of  in- 
grow^ths  of  germinal  epithelium  into  the  stroma.  This  tendency  of  the  epi- 
thelium surrounding  the  ovary  to  inversion  often  persists,  and  the  cutting  off 
in  the  stroma  of  such  cell-inclusions  undoubted^  is  the  basis  of  many  ovarian 
new-growth  tumors. 

The  ova,  or  germ-cells,  are  distinguished  from  the  other  cells  by  their  greater 


440 


GYNECOLOGY 


size.  They  are  found  included  in  the  cell  masses  above  described  and  scattered 
through  the  investing  layer  of  germinal  epithelium.  After  birth  there  is  no 
further  generation  of  new  follicles.  During  the  first  year  many  of  the  primordial 
follicles  already  created  disappear. 

Descent  of  the  Ovaries. — At  about  the  third  month  of  embryonal  life  the 
descent  of  the  ovaries  takes  place.  The  gubernacul"um  of  Hunter,  which  at 
first  represents  an  abdominal  fold,  later  becoming  endowed  with  connective 
tissue  and  muscle-fibers,  connects  the  Wolffian  body  with  the  inguinal  canal  at 


\\)\y(V r    ^    _^  ^ 

FiG.  169. — Diagram  Showing  Descent  of  Ovaries  and  Fusion  of  Mtjller's  Ducts  into  Uterus 

AND  Vagina. 
The  way  in  which  the  gubernaculum  of  Hunter  becomes  the  round  and  ovarian  ligaments  is  shown. 

an  early  period.  At  the  time  when  the  Wolffian  body  is  in  the  process  of  retro- 
gression this  ligament  fails  to  keep  pace  with  the  growth  of  the  rest  of  the  body, 
and  exerts  such  traction  on  the  genital  gland  that  it  is  drawn  dow^nward  into 
the  pelvis.  The  gubernaculum  of  each  side  fuses  in  its  upper  third  with  the 
Mtiller's  ducts  at  their  point  of  union  (fundus  of  the  uterus),  so  that  finally  it  is 
divided  into  two  unequal  portions,  one  that  extends  from  the  fundus  to  the 
inguinal  canal,  the  round  ligament,  and  one  that  runs  from  the  fundus  to  the 
ovary,  the  suspensory  ligament  of  the  ovary. 


DEFECTS    OF    DEVELOPMENT 


441 


Before  full  sexual  development  the  ovaries  remain  relatively  high,  their 
complete  descent  into  the  depth  of  the  pelvis  being  consummated  after  maturitj'-, 
due  possibly  to  the  gradual  increase  in  weight  of  the  organ.  (Adapted  from 
Otto  Klistner,  in  Kiistner's  Lehrbuch.) 

The  Wolffian  and  Miiller's  ducts  primarily  open  below  into  the  lower  part 
of  the  allantois,  which  at  this  time  represents  an  anterior  extrusion  of  the  end- 
gut  from  the  body  cavity.  Later  the  walls  of  the  abdomen  join  in  the  mid-line 
up  to  the  umbilicus,  and  the  portion  of  the  allantois  between  the  umbilicus  and 
the  openings  of  the  Wolffian  and  Miiller's  ducts  becomes  the  bladder  and  urethra. 
Below  this  level  the  descending  part  of  the  canal  is  termed  the  "urogenital  sinus," 
while  the  ascending  part  is  the  rectum.  The  part  into  which  these  two  canals 
empty  in  common  is  called  the  '^cloaca." 

CONGENITAL  DEFECTS  OF  THE  UTERUS 

Defects  of  the  uterus  occur  chiefly  as  a  result  either  of  complete  or  partial 
failure  of  union  of  the  two  Mlillerian  ducts.  An  entire  absence  of  uterine  tissue 
does  not  occur,  for  even  in  the  cases  of  congenital  absence  of  the  vagina  there  is 


FiG.  170. — Uterus  Duplex  Bicornis  cum  Vagina  Duplici. 

Double  Vagina. 
Normal  in  the  opossum. 


Double  Bicornuate  Uterus  with 


always  a  rudimentary  development  of  the  uterus,  which  som.etimes  exists  only 
as  a  small  retroperitoneal  sohd  strand  of  tissue  scarcely  appreciable  by  rectal 
examination. 

Failure  of  union  of  the  Mlillerian  ducts  may  result  in  the  following  abnormal 
formations : 

(1)  Uterus  didelphj^s,  or  uterus  duplex  separatus.  This  signifies  a  com- 
plete separation  of  the  two  halves  of  the  uterus  with  double  vagina.    This  form 


442 


GYNECOLOGY 


is  rarely  seen  in  living  human  individuals,  being  usually  associated  with  other 
malformations  of  the  pelvis  that  are  incompatible  with  life. 


-\\i  p 


Fig.  171. — Uterus  Duplex  Bicornhs.     Double  Uterus. 
Normal  in  the  squirrel,  hare,  and  beaver. 


(2)  Uterus  duplex  bicornis  cum  vagina  duphci.  In  this  case  there  is  a  separa- 
tion of  the  two  bodies,  but  the  two  cervices  are  fused.  The  vagina  is  double 
(Fig.  170). 


Fig.  172. — Uterus  Bicornis  Unicollis.     Bicornuate  Uterus. 
Normal  in  the  hyena,  dog,  goat,  and  sheep. 

(3)  Uterus  duplex  bicornis.      Here  the  formation  is  like  the  preceding- ex- 
cept that  there  is  a  single  vagina. 

(4)  Uterus  bicornis  unicolhs.     In  this  type  the  body  of  the  uterus  is  double, 


DEFECTS    OF    DEVELOPMENT 


443 


but  the  cervix  is  fused  into  one.     The  two  bodies  may,  however,  not  be  widely 
separated,  but  lie  closely  together  so  that  the  fundus  has  a  saddle  shape. 

(5)  Uterus  septus  duplex.  The  external  form  of  the  uterus  is  entirely 
norinal,  but  the  entire  canal  is  divided  by  a  septum  reaching  from  the  fundus  to 
the  external  os. 

(6)  Uterus  subseptus  uniforis.  The  external  contour  is  normal,  but  there 
exists  a  partial  septum  extending  from  the  fundus. 


Fig.  173.- 


-Uterus  Subseptus  Uniforis.     Partial  Septum  of  the  Uterine  Cavity. 
Normal  in  the  horse  and  the  ass. 


Fig.  174. — Uterus  Biforis. 

The  uterine  cavity  is  single,  the  cervical  canal 

is  double.     Normal  in  the  ant-eater. 


Fig.  175. — Uterus  Unicornis. 

The  adnexa  of  one  side  are  wanting.       Normal 

in  birds. 


(7)  Uterus  biforis.  The  canal  of  the  body  is  normal,  but  a  septum  divides 
the  cervix  completely  so  that  there  is  a  double  orifice  (Fig.  174). 

(8)  Uterus  unicornis.  In  this  form  there  is  complete  absence  of  one-half  of 
the  uterus  (Fig.  175). 

The  foregoing  are  the  essential  malformations,  but  they  may  assume  various 
forms  as  a  result  of  unequal  development  in  the  two  sides.  If  both  halves  of  a 
double  uterus  develop  equally,  both  may  functionate  perfectly — i.  e.,  menstruate 
and  conceive.  Usually  in  double  uterus  one-half  is  better  developed  than  the 
other,  and  if  repeated  pregnancies  take  place  they  occur  in  the  same  half.    One- 


444  GYNECOLOGY 

half  may  be  diseased  with  cancer  or  bacterial  infection,  while  the  other  remains 
entirely  unaffected.  The  opening  of  one-half  of  a  double  uterus  may  become 
closed,  with  resulting  hematometra.  When  one  horn  of  a  double  uterus  is  in- 
completely developed  there  may  be  a  congenital  atresia  of  its  canal,  and  this 
may  also  eventuate  in  a  hematometra.  The  symptoms  of  these  two  conditions 
are  the  same  as  those  described  under  the  subject  of  Gynatresia.  Pregnancy  may 
occur  in  a  rudimentary  horn.  If  there  is  a  communication  between  the  rudi- 
mentary horn  and  the  main  uterine  canal  an  abortion  may  take  place  through 
the  opening.  Sometimes,  however,  a  rudimentary  horn  which  has  no  com- 
munication with  the  uterine  canal  may  become  impregnated  by  a  wandering 
fertilized  ovum  from  the  opposite  side.  The  clinical  picture  is  then  one  of  tubal 
pregnancy. 

Double  formation  of  the  uterus,  as  a  rule,  has  no  special  chnical  significance 
unless  there  is  atresia  and  hematometra.  The  diagnosis  is  usually  difficult  to 
make.  If  sepsis  is  not  present,  and  one-half  of  the  uterus  is  normal,  the  atretic 
half  may  be  amputated. 

Where  pregnancy  takes  place  in  a  rudimentary  horn  the  treatment  is  the 
same  as  that  of  extra-uterine  pregnancy,  with  amputation  of  the  rudimentary 
horn  if  the  other  uterine  body  and  adnexa  are  normal. 

DEVELOPMENTAL  DEFECTS  OF  THE  VAGINA 

Most  cases  of  defective  vagina  that  produce  symptoms  are  the  result  of 
inflammatory  processes  acquired  after  birth,  as  described  in  detail  under  the 
heading  of  Gynatresia  (g.  v.). 

The  developmental  defects  have  chiefly  to  do  with  entire  absence  of  the 
vagina  or  to  septum  formation,  or  to  the  union  of  two  abnormally  narrow  Miil- 
lerian  ducts. 

In  most  cases  of  congenitally  absent  or  defective  vagina,  except  where 
there  is  septum  formation,  the  uterus  is  functionless,  so  that  no  symptoms  of 
retained  secretions  ensue  at  puberty,  as  in  the  case  of  acquired  gynatresia. 
It  often  happens,  however,  that  individuals,  even  with  complete  absence  of 
the  vagina  and  with  rudimentary  internal  genital  organs,  may  be  otherwise 
fully  developed  both  as  to  external  genitals  and  the  secondarj^  bodily  sexual 
characteristics.  These  women  may  have  normal  sexual  instincts,  and  are 
often  so  attractive  as  to  be  sought  in  marriage.  In  such  cases  it  sometimes  be- 
comes necessary  to  create  an  artificial  vaginal  pouch  for  the  purpose  of  co- 
habitation. 

In  performing  this  operation  it  is  first  necessary  to  separate  the  bladder  from 
the  rectum,  which  are  united  along  the  area  normally  occupied  by  the  vagina. 
A  space  is  made  by  blunt  dissection  corresponding  to  the  size  of  the  normal 
vagina.  The  next  step  is  to  line  this  newly  made  pouch  with  an  epithelial  sur- 
face, as  otherwise  the  raw  surfaces  cannot  be  kept  from  readhering.     This  may 


DEFECTS    OF    DEVELOPMENT  445 

be  accomplished  by  turning  in  flaps  from  the  labia  minora  and  from  the  skin  of 
the  buttocks.  A  better,  though  more  dangerous  operation,  is  to  bring  down 
through  an  opening  into  the  peritoneal  cavity  a  resected  loop  of  the  intestine,  to 
which  is  attached  its  corresponding  section  of  mesentery.  The  pouch  can  thus 
be  lined  with  a  true  mucous  membrane,  which  is  kept  alive  by  its  mesenteric 
circulation.  An  abdominal  operation  is  necessary  for  the  resection  of  the  bowel 
and  the  union  of  the  bowel-ends.  The  details  of  both  methods  of  operation 
are  described  in  Part  III. 

A  third  method  is  also  described   by  which  an  artificial  vagina  is  formed 
from  a  section  of  the  rectum. 


DEVELOPMENTAL  DEFECTS  OF  OVAREES  AND  TUBES 

Absence  of  both  ovaries  occurs  only  in  non-viable  fetuses  in  which  there 
is  complete  absence  of  genital  elements.  The  failure  of  one  ovary  is  seen  in 
uterus  unicornis  or  where  one  horn  is  extremely  rudimentary. 

On  the  other  hand,  an  accessory  ovary  is  sometimes,  though  rarely,  seen. 
Whether  the  third  ovary  represents  an  independent  separate  growth  from  the 
start,  or  whether  it  was  accidentally  cut  off  from  the  normal  ovary  during 
early  embryonal  life,  is  a  matter  of  doubt. 

Absence  of  the  tubes,  like  absence  of  the  ovaries,  occurs  only  on  one  side  in 
the  case  of  uterus  unicornis. 

Imperfect  or  hypoplastic  development  is  discussed  under  the  subject  of 
Infantilism. 

DEFECTS  OF  THE  URETHRA  AND  BLADDER 

Hypospadias  in  the  female  differs  essentially  from  that  seen  in  the  male. 
In  the  latter  it  relates  to  an  opening  of  the  urethra  on  the  under  side  of  the 
penis,  at  any  point  from  the  glans  to  the  colliculus  seminalis.  This  part  is 
wanting  in  the  female,  in  whom  the  urethra  corresponds  to  that  portion  of  the 
male  canal  which  extends  from  the  colliculus  to  the  bladder. 

Female  hypospadias  may  represent  various  grades  of  deficiency,  from  mod- 
erate defects  of  development  to  complete  absence  of  the  urethral  canal. 

When  the  urethra  is  entirely  wanting  there  is  a  funnel-shaped  opening  into 
the  bladder,  so  that  there  appears  to  be  a  communication  between  the  bladder 
and  vagina.  It  should  be  remembered,  however,  that  in  embryonal  life  the 
urinary  system  at  no  time  communicates  with  the  Miillerian  ducts,  so  that  in 
complete  hypospadias  the  urethral  opening  is  really  into  the  vestibule.  When 
the  defect  of  the  urethra  is  complete,  there  is  also  an  absence  of  the  sphincter 
vesicae  with  full  incontinence  of  urine.  When  the  urethra  is  incompletely 
developed  the  incontinence  may  be  only  partial. 

The  treatment  of  hypospadias  is  operative,  and  is  directed  to  the  control  of 


446 


GYNECOLOGY 


the  urine.  If  the  hypospadias  is  complete  the  success  of  the  operation  is  always 
in  doubt.  If,  however,  the  defect  is  partial  and  the  vesical  sphincter  muscle  is 
present,  a  skilfully  performed  plastic  operation  should  cure  the  patient.  The 
operative  technic  must  be  determined  somewhat  by  the  exigencies  of  the  case, 
but  may  be  carried  out  on  the  general  principles  recommended  for  Incontinence 
(see  page  614). 


VXreWfo^ 


Fig.  176.  ^Epispadias. 


Exstrophy  and  epispadias  are  comparatively  rare  conditions  in  the  female. 
Both  these  malformations  are  different  grades  of  the  same  embryonic  defect. 

In  the  early  stages  of  development  the  cloacal  membrane  reaches  to  the 
primitive  belly-stalk  or  forerunner  of  the  umbihcal  cord.  As  the  embryo  grows 
the  upper  portion  of  this  membrane  disappears  as  the  sides  of  the  abdominal 
wall  and  pelvis  join,  while  the  lower  part  corresponds  to  the  opening  of  the  uro- 
genital sinus  and  the  rectum. 


DEFECTS    OF    DEVELOPMENT 


447 


Under  abnormal  conditions  the  cloacal  membrane  may  partially  or  entirely 
persist,  due  to  the  incomplete  merging  in  the  middle  line  of  the  sides  of  the 
muscular  abdominal  wall  or  of  the  pelvis.     The  thin  epithelial  cloacal  membrane 


3k\\  CXYvWiS .^ 

i"l'(\test\Yie- 

- 

1* 

^^JjcvCtr 

CVoaecA.            m 

grpomtot- 

3^e.-m\>raxvs^ 

^ 

bucks' 

^^  ^loo^co. 

W 

Fig.  177. — Common  cloaca  into  which  the 
gut  and  the  allantois  empty.  The  cloacal  mem- 
brane reaches  to  the  region  of  the  later  bladder 
and  urethra.  Knowledge  of  this  membrane  is 
important  in  understanding  exstrophy  of  the 
bladder  (Pankow). 


3iUvb6t<-     Got 


iVTuUev" 


Fig.  178. — The  cloaca  separates  into  a  ven- 
tral and  dorsal  part.  The  Wolffian  ducts  open 
into  the  ventral  part.  Miiller's  ducts  at  this 
stage  are  not  established.  The  dotted  line  shows 
the  position  of  their  later  development.  The 
beginning  of  the  bladder  can  be  seen  as  a  dilata- 
tion in  the  duct  of  the  allantois  (Pankow) . 


thus  exposed  soon  breaks  and  allows  the  urinary  contents  of  the  bladder  to 
escape  through  the  opening  of  the  belly  wall.     If  the  opening  is  extensive  the 


— =  ~-= 

.)v("u!lfc«^ 

^^&W,t[(. 

^=^,,^\)Vetetr 

C\onco>V^Si^;^*.^        _,-^       /                   

\            ■ ■                  .  = 

r 

Fig.  179. — ^The  sinus  urogenitalis  is  formed.  The  ureter  is  seen  sprouting  from  the  Wolffian 
duct.  The  Miiller's  ducts  have  at  this  stage  not  yet  reached  the  sinus,  urogenitalis,  their  future 
position  being  shown  by  the  dotted  lines  (Pankow). 


condition  is  called  exstrophy  of  the  bladder.  The  extrusion  of  the  bladder  is  due 
to  abdominal  pressure  which  forces  the  posterior  bladder  wall  out  through  the 
abdominal  opening. 


448 


GYNECOLOGY 


Fig.  180. — The  urogenital  sinus  has  broken  through  the  cloacal  membrane.  The  intestine  is 
still  closed.  The  Miillerian  ducts  have  reached  the  urogenital  sinus  to  the  median  side  of  the 
Wolffian  ducts,  but  have  not  yet  acquired  an  open  lumen.  The  site  of  the  future  hymen  is 
indicated.  The  ureter  has  separated  from  the  Wolffian  duct.  The  part  between  the  ureter  and 
Miiller's  ducts  becomes  the  lower  part  of  the  bladder  and  the  urethra.  Douglas'  pouch  is  in- 
dicated between  the  gut  and  the  urogenital  sinus.  The  shaded  portion  protruding  to  the  left  of  the 
drawing  represents  the  genital  tubercle,  the  future  clitoris  (Pankow). 


Fig.  181. — The  urethra  and  vagina  open  into  the  common  urogenital  sinus,  which  gradually 
gets  shorter  and  shorter,  eventually  becoming  the  vestibule.  The  perineum  is  developed.  The 
rectum  has  established  an  opening  through  the  anal  dimple.  The  lumen  of  vagina  and  uterus  has 
been  formed  (Pankow). 


If  the  defect  takes  place  so  that  only  the  upper  part  of  the  bladder  is  ex- 
posed the  condition  is  called  a  superior  vesical  fissure;  if  the  defect  is  in  the 


DEFECTS    OF    DEVELOPMENT 


449 


lower  part  of  the  bladder  it  is  called  inferior  vesical  fissure.  If  the  separation 
is  confined  to  the  urethra  and  the  vulva  the  condition  is  termed  epispadias. 

Inferior  vesical  fissure  and  epispadias  may  be  combined. 

In  exstrophy  and  fissure  of  the  bladder  the  urine  usually"  passes  completely 
through  the  abdominal  opening.  In  epispadias  incontinence  may  be  complete 
or  partial,  or  even  absent  in  mild  grades  of  the  deformity. 

Treatment  is  directed  toward  control  of  incontinence,  and  can  be  accom- 
plished onl}^  by  plastic  surgery.  Operations  for  exstrophy  are  difficult,  and  must 
usualh^  be  repeated  several  times  before  success  can  be  attained.  For  moderate 
degrees  of  epispadias  operations  may  be  successful,  but  patients  should  always 
be  told  that  it  may  require  several  or  even  many  operations  before  a  cure  can  be 
effected. 

ATRESIA  OF  THE  ANUS 

This  term  is  applied  to  a  condition  in  which  the  normal  communication 
between  the  rectum  and  the  outside  world  was  not  established  during  the 
process  of  development.      In  viable  children  two  types  of  atresia  are  to  be 


CUlons--- 
Aac\bvuvv\)\lV 


Svnus  UfoofctaTcxUs 


Fig.  182. — Section  of  Normal  Infant's  Pelvis. 


distinguished:  (1)  where  the  lowest  portion  of  the  rectum  is  deficient  and  the 
bowel  ends  in  a  bhnd  pouch,  and  (2)  where  the  embryonal  communication  be- 
tween the  rectum  and  urogenital  sinus  persists.  In  the  latter  case,  in  the  full- 
term  child,  the  rectum  opens  into  the  vestibule. 

True  atresia  of  the  rectum  is  properly  applied  only  to  the  first  tj^'pe.  This 
condition  is  discovered  soon  after  birth  by  the  absence  of  defecation,  and  re- 
quires immediate  operative  interference.      Occasionally  the  atresia  is  due  to 

29 


450 


GYNECOLOGY 


a  simple  gluing  together  of  the  superficial  epithelium,  in  which  case  an  open- 
ing is  easily  made  by  blunt  puncture.     If  there  is  more  than  a  thin  membrane 


FiG.  1S3. — Imperforate  Antts. 


between  the  rectal  pouch  and  the  external  anal  dimple  the  operation  is  a  serious 
one  and  accompanied  by  a  high  eventual  mortality.     The  operation  consists 


Fig.  184. — Vestibular  A?gx^s. 


in  making  an  anteroposterior  incision  through  the  anal  dimple,  dissection  of  the 
intervening  tissue,  and  bringing  the  rectum  down  to  the  incision,  to  which  it  is 


DEFECTS    OF    DEVELOPMENT  451 

sutured.  In  all  cases  the  sphincter  muscle  is  present,  so  that,  if  the  operation 
is  skilfully  performed,  complete  control  of  the  bowels  is  secured.  Manj^  suc- 
cessful cases  have  been  reported. 

Anus  vestibularis  is  the  term  applied  to  the  second  type  of  anal  atresia.  In 
this  condition  there  is  no  opening  through  the  anal  dimple,  but  the  former 
embryonal  opening  into  the  urogenital  sinus  persists  (Fig.  184).  As  the  vestibule 
in  such  cases  is  often  deeply  placed,  the  rectal  communication  appears  to  be  in 
the  vagina,  and  for  this  reason  the  condition  is  sometimes  spoken  of  as  a  vaginal 
anus.  This  is  incorrect,  as  a  connection  between  the  rectum  and  Miiller's 
duct  is  embryologically  impossible.  The  defect  should  always  be  termed 
"vestibular  anus"  (Pankow). 

If  the  opening  into  the  vestibule  is  very  small,  there  may  be  obstruction  to 
defecation  and  the  newborn  child  may  require  surgical  operation.  Usually, 
however,  the  opening  is  large  enough  to  permit  the  passage  of  feces,  and  patients 
with  this  defect  often  grow  to  adult  life  without  knowledge  of  their  condition. 
Some  even  conceive  and  bear  children.  Operation  is,  however,  sometimes 
indicated  if  there  is  incontinence  and  uncleanHness,  especially  in  women  who 
contemplate  marriage.  The  operation  is  not  difficult,  and  usually  results  in 
perfect  success.  The  rectal  pouch  is  brought  down  to  an  opening  through  the 
anal  dimple  and  sutured  there,  and  a  new  anus  estabhshed.  The  old  vestibular 
anus  is  denuded  and  closed  by  suture. 

HERMAPHRODITISM 

The  sex  of  an  individual  is  determined  only  by  the  nature  of  the  genital 
glands  (i.  e.,  as  to  whether  they  are  ovaries  or  testes),  and  not  by  the  appearance 
of  the  external  genitals,  nor  by  the  development  of  the  secondary  sexual  char- 
acters of  the  body. 

True  hermaphroditism  implies  the  presence  in  the  same  individual  of  both 
ovarian  and  testicular  tissue,  fully  developed  and  functionating.  There  are 
numerous  instances  of  true  hermaphroditism  in  some  of  the  lower  species  of 
animal  life,  but  in  man  it  has  never  been  demonstrated  and  probably  does  not 
exist,  though  several  cases  have  been  reported  in  which  there  has  been  found  in 
the  genital  glands  both  ovarian  and  testicular  tissue,  the  so-called  ovitestes. 
In  all  of  these  cases  only  the  elements  of  one  sex  were  fully  developed  and  capable 
of  function.  Such  individuals  could,  therefore,  not  be  termed  true  hermaph- 
rodites. 

The  sexual  intermediates  that  appear  in  the  human  species  are  always  essen- 
tially male  or  female,  though  they  may  have  the  outward  characteristics  of  the 
opposite  sex.  They  are,  therefore,  properly  designated  as  "pseudohermaphro- 
dites." 

Pseudohermaphrodites  are  divided  into  two  classes — feminine  and  mascu- 
line.    In  individuals  of  the  former  class  the  structure  of  the  genital  glands  is 


452  GYNECOLOGY 

ovarian,  but  external  genitalia  and  the  secondary  sexual  characteristics  are  of 
the  male  type.     This  class  is  comparatively  rare. 

Most  pseudohermaphrodites  possess  the  male  genital  gland,  but  are  out- 
wardly more  of  the  feminine  type.  In  these  individuals  the  penis  is  rudi- 
mentary and  is  not  perforated  by  the  urethral  canal.  The  meatus  urinarius 
lies  at  the  base  of  the  rudimentary  penis  and  often  cannot  be  seen,  especially 
in  children,  as  it  opens  into  a  blind  depression  which  closely  resembles  a  vagina. 
The  testes  are  either  undescended  or  lie  high  up  in  separated  scrotal  sacs,  which 
may  have  the  exact  appearance  of  labia  majora.  Individuals  of  this  kind  are 
usually  regarded  in  childhood  as  girls,  are  given  feminine  names,  and  grow  up  as 
females.  Sometimes  male  characteristics  may  develop  as  the  child  comes  to 
maturity  and  call  attention  to  the  real  sex.  It  is  sometimes  impossible  to  make 
a  diagnosis  of  the  correct  sex  except  by  microscopic  examination  of  the  sexual 
gland,  a  procedure  which  under  ordinary  circumstances  is  not  feasible. 

There  may  be  great  variations  in  the  type  of  pseudohermaphroditism  just 
described,  depending  on  the  development  of  the  genital  organs.  The  elements 
representing  Miiller's  ducts  are,  as  a  rule,  rudimentary,  but,  on  the  other  hand, 
they  may  develop  into  nearly  full-sized  uterus,  tubes,  and  vagina.  At  least  one 
case  has  been  reported  of  an  individual  who  lived  and  cohabited  both  as  a  man 
and  as  a  woman. 

The  testes  of  the  pseudohermaphrodite  possess  a  special  predisposition  to 
malignant  degeneration. 


Malpositions  of  the  Uterus 


When  a  woman  is  standing  the  uterus  lies  normally  in  approximately  a 
horizontal  position.  The  anterior  wall  is  in  contact  with  the  bladder,  while  on 
the  posterior  wall  and  in  the  recto-uterine  pouch  rest  the  intestines.  This 
position  of  the  uterus  is  not  a  fixed  one,  for,  owing  to  the  requirements  of  child- 
birth, the  organ  is  necessarily  mobile.  Thus,  by  manipulation  it  can  be  rotated 
backward  through  an  angle  of  180  degrees,  while  laterally  it  can  be  turned 
through  an  angle  of  45  degrees  to  each  side. 
Pressing  as  it  does  on  the  wall  of  the  bladder, 
its  position  is  continually  changing  in  an 
anteroposterior  plane,  accommodating  itself 
automatically  to  the  varying  changes  in  the 
size  of  the  bladder.  Nor  is  its  level  in  the 
pelvis  a  fixed  one,  for  under  the  influence  of 
forced  abdominal  pressure,  such  as  results 
from  straining,  the  elastic  supports  of  the 
uterus  allow  a  certain  amount  of  descent  in 
the  direction  of  the  pubic  outlet. 

The  uterus,  notwithstanding  its  remark- 
able mobihty,  nevertheless  under  normal 
conditions  returns  to  its  proper  position 
after  temporary  displacement,  such  as  may 
result  from  forcible  manipulation,  pregnancy,  severe  strains,  rapidly  growing 
tumors,  or  any  influence  that  does  not  cause  a  fundamental  change  in  the 
elasticity  of  its  supports  or  its  inherent  muscular  structure. 

The  axis  of  the  uterus  is  not  normally  straight,  for  there  exists  between  the 
body  and  cervix  a  moderate  permanent  angulation  or  anteflexion  which  has  a 
considerable  variation  within  normal  limits.  After  the  menopause  the  normal 
angulation  disappears  and  the  axis  of  the  uterus  becomes  straight. 

The  nomenclature  of  uterine  displacements  has  not  been  standardized. 
The  following  terms  and  definition's,  though  not  in  all  particulars  universally 
employed,  have  received  the  sanction  of  good  usage: 

Retroversion  of  the  uterus  means  a  turning  backward  of  the  entire  organ  on 
an  axis  situated  approximately  at  the  internal  os.  In  an  uncomplicated  retro- 
version the  cervix  and  body  retain  their  normal  relationship  to  each  other,  so 
that  as  the  body  turns  backward  the  cervix  points  forward.  For  the  sake  of 
convenience,  retroversion   is   divided  into  three  degrees:   The  first  degree  in- 

453 


Fig.  185. — Normal  Position  of 
Uterus. 


454 


GYNECOLOGY 


eludes  deviations  from  the  normal  position  to  a  point  where  the  long  axis  of  the 
uterus  coincides  with  the  long  axis  of  the  vagina.     At  this  point  the  uterus  is 


Pig.  186. — Retroversion.     First  Degree. 


Fig.  187. — Retroversion.     Second  Degree. 


said  to  be  in  the  second  degree  of  retroversion,  and  the  cervix  points  in  the 
direction  of  the  vaginal  orifice.     Deviations  beyond  the  second  degree  are  said 


Fig.  188. — Retroversion.     Third  Degree,  with  Retroflexion. 

to  be  in  the  third  degree,  and  the  cervix  tends  to  point  correspondingly  further 
forward. 


MALPOSITIONS    OF    THE    UTERUS 


455 


Anteversion  means  a  turning  forward  of  the  uterus.  As  a  matter  of  fact, 
the  uterus  in  its  normal  position  is  turned  forward  as  far  as  it  can  go,  resting  as 
it  does  on  the  bladder.  The  term  "anteversion,"  therefore,  describes  the  normal 
position  of  the  uterus  and  does  not  denote  a  displacement,  as  it  was  formerly- 
supposed.    The  term  is  rarely  used  at  present. 

Lateral  version  means  a  turning  of  the  uterus  to  the  right,  or  left. 

Retroflexion  of  the  uterus  means  a  bending  backward  of  the  body  on  the 
cervix,  causing  an  angulation  of  the  posterior  wall.  The  flexion  takes  place  at 
the  internal  os.  It  is  usually  a  more  advanced  manifestation  of  retroversion, 
and  does  not  occur  until  the  uterus  has  reached  the  third  degree  of  retroversion. 
When  retroversion  and  retroflexion  are  combined  it  is  customary  to  say  that  the 
uterus  is  in  a  position  of  retroversion-flexion. 


Fig.  189. — Lateral  Version. 


Fig.  190. — Lateral  Flexion. 


Lateral  flexion  means  a  bending  of  the  uterine  body  on  the  cervix  to  the 
right  or  left.  If  there  has  been  also  a  version  involving  the  cervix,  one  speaks  of 
right  or  left  version-flexion. 

Anteflexion  relates  to  forward  angulation  between  the  body  and  cervix. 
The  uterus  is  normally  anteflexed  to  a  certain  degree.  The  term  "anteflexion" 
is  used  to  denote  an  abnormal  amount  of  angulation.  The  condition  is  de- 
scribed more  exactly  by  hyperanteflexion,  a  word  that  is  not  in  common  use. 

Retrocession  is  a  specialized  term  that  relates  to  a  condition  in  which  the 
uterus  has  receded  to  a  position  nearer  the  sacrum  than  normal,  but  in  which 
the  fundus  continues  to  point  forward.  In  the  majority  of  anteflexion  cases 
the  whole  uterus  is  abnormally  far  back,  and  is  said,  therefore,  to  be  retro- 
cessed.  Conversely,  retrocession,  when  properly  used,  implies  an  anteflexion 
of  the  body. 


456 


GYNECOLOGY 


Anteposition  denotes  that  the  uterus,  as  a  whole,  is  in  a  position  abnormally 
near  the  pubes  or  anterior  abdominal  wall.     This  position  is  created  by  the 


.^orrnoV  Jtx\s 


jVx\s    oC 


Fig.  191. — Anteflexion  with  Retrocession. 
The  whole  uterus  sags  back  toward  the  sacrum. 

pressure  from  behind  of  a  tumor  situated  in  the  posterior  culdesac,  or  by  ab- 
normal attachment  of  the  fundus  to  the  anterior  abdominal  wall. 


Fig.  192. — Retroversion  and  Prolapse  (Descensus)  of  the  Uterus. 

Retroposition  and  retrolocation  are  terms  vaguely  used,  and  may  include 
retroversion,  retroflexion,  and  retrocession. 


MALPOSITIONS    OF    THE    UTERUS 


457 


Prolapse  of  the  uterus  denotes  a  permanent  descent  of  the  uterus  from  its 
physiologic  level  in  the  direction  of  the  vaginal  introitus.  The  word  descensus 
describes  the  condition  more  accurately,  but  is  not  as  commonly  used.  The 
term  "prolapse"  relates  to  all  degrees  of  descent  of  the  uterus  until  the  cervix 
reaches  the  vaginal  introitus. 

Procidentia  denotes  extreme  prolapse,  and  includes  all  conditions  in  which 
the  cervix  extrudes  from  the  vaginal  introitus  (Fig.  193). 


Uterus  uii\k£ionpate^  a-rib 


V  osYevvor  \\lcM 


Fig.  193. — Procidentia  Showing  Elongation  and  Hypertrophy  of  the  Cervix. 

Complete  procidentia  is  used  to  designate  the  extrusion  of  the  entire  organ 
from  the  vaginal  orifice  (Fig.  194). 

The  word  "prolapse"  is  sometimes  applied  to  the  vaginal  wall.  When  used  in 
this  sense,  prolapse  of  the  anterior  vaginal  wall  corresponds  to  a  cystocele,  while 
prolapse  of  the  posterior  wall  is  identical  with  a  rectocele. 

Torsion  of  the  uterus  means  a  twisting  of  the  body  on  the  cervix  in  the  ver- 
tical axis. 


458 


GYNECOLOGY 


\iaQvT\oA  VicxW- 


NaomolWall 


Fig.  194. — Complete  Procidentia. 
The  entire  uterus  is  outside  of  the  body. 

Elongation  of  the  uterus  means  a  lengthening  of  the  organ  by  pressure, 
tension,  or  hypertrophy.  The  elongation  may  occur  in  the  body,  in  the  cervix, 
or  in  both. 

Inversion  of  the  uterus  means  a  turning  inside  out  of  the  entire  organ. 


RETROVERSION  AND  RETROFLEXION 

Etiology. — We  have  seen  that  the  uterus  during  the  erect  posture  lies  in  a 
horizontal  plane,  with  the  anterior  surface  resting  on  the  fundus  of  the  bladder, 
while  abdominal  pressure  is  exerted  on  the  posterior  uterine  surface  through  the 
medium  of  the  intestines. 

In  general,  the  uterus  is  maintained  in  its  normal  forward  position  by  three 
factors:  first,  by  the  proper  tone  of  its  anatomic  supports;  second,  by  the  elas- 
ticity of  its  musculature;  third,  by  the  abdominal  pressure  which  serves  to 
keep  the  anterior  uterine  wall  in  contact  with  the  bladder.  Backward  rota- 
tion of  the  uterus  occurs  when  these  factors  cease  to  exert  their  proper  influence, 
and  this  may  happen  in  the  following  ways: 

(1)  The  supporting  tissues  of  the  uterus  or  its  own  musculature  may  be- 


MALPOSITIONS    OF    THE    UTERUS 


459 


come  permanently  weakened,  so  that  the  fundus  sags  back  from  the  bladder. 
This  allows  the  intestines  to  enter  the  vesico-uterine  space,  so  that  abdominal 
pressure  is  now  exerted  on  the  anterior  surface  of  the  uterus,  and  serves  gradually 
to  force  it  backward  into  the  posterior  culdesac.  The  weakened  supports  of  the 
uterus  cannot  cope  with  the  force  of  the  abdominal  pressure  and  the  retroversion 
becomes  permanent. 

(2)  The  fundus  of  the  uterus  may  be  forcibly  and  permanently  dragged 
back  by  the  formation  and  shrinking  of  adhesions  that  form  between  its  poste- 
rior surface  and  the  rectum  and  pelvic  wall,  or  by  tumors  attached  to  the  poste- 
rior wall. 

(3)  The  uterus  may  be  pushed  back  by  various  tumor  growths. 

A  special  fourth  type  comprises  cases  where  the  uterus  has  developed  in  the  posterior  posi- 
tion. This  type,  however,  would  properly  be  included  in  the  first-mentioned  class,  as  the  con- 
dition is  undoubtedly  due  to  a  congenital  deficiency  in  the  uterine  supports  or  musculature. 

Each  one  of  these  types  presents  special  clinical  features,  and  we  shall, 
therefore,  consider  them  separately. 

RETROVERSION  DUE  TO  RELAXATION 

Lax  pelvic  supports  may  be  acquired  by  pregnancy  and  childbirth,  or  they 
may  be  due  to  a  phj^siologic  insufficiency  of  tissue  in  the  suspensory  apparatus, 
or  they  may  result  from  a  combination  of  both  causes. 

By  far  the  greatest  number  of  retroversions  follow  child-bearing.  The 
tissues  of  the  uterus  and  of  all  its  supporting  structures  are  enormously  hyper- 
trophied  and  stretched  during  pregnancy.  These  tissues  by  normal  involution 
return  nearly  but  not  quite  to  their  original  form  and  tonicity.  Permanent 
laxness  of  these  tissues  results  from  an  incomplete  involution  of  the  parts  after 
the  puerperium.  This  may  be  brought  about  by  various  factors.  The  impor- 
tant cause  is  a  congenital  insufficiency  inherent  in  the  tissues  themselves.  Indi- 
viduals differ  greatly  in  respect  to  the  tone,  elasticity,  and  recuperative  power 
of  their  supporting  tissues,  as  is  shown  by  the  fact  that  some  women  who  have 
borne  many  children  often  show  astonishingly  little  damage  to  their  pelvic 
supports,  while  in  others  only  one  childbirth  may  result  in  the  most  extreme 
displacements.  In  the  latter  case  the  patients  often  present  other  evidence 
of  deficient  tissue-supporting  strength,  such  as  enteroptosis,  diastasis  of  the 
abdominal  recti,  etc.  Rapid  and  frequent  pregnancies  may  result  in  permanent 
laxity  of  pelvic  support  even  in  those  naturally  endowed  with  good  tissues. 
The  early  getting  up  from  child-bed  is  an  occasional  factor  in  the  causation  of 
retroversion,  but  its  frequency  is  probably  exaggerated. 

The  social  condition  of  the  patient  undoubtedly  plays  an  important  part. 
It  has  been  our  experience  to  find  displacements  following  child-bearing  far 
more  .frequent  among  the  working  class  than  among  the  well-to-do.  This  is 
only  partly  explained  by  the  better  physical  inheritance  that  the  well-to-do  in 


460  GYNECOLOGY 

general  possess.  Other  causes  are  more  important.  Poor  women  work  hard 
and  continuously  during  the  period  of  pregnane}^,  most  of  them  without  efficient 
abdominal  support.  The  strain  of  constant  severe  abdominal  pressure  neces- 
sitated by  physical  work,  and  unrelieved  by  proper  rest  or  support,  must  produce 
a  greater  stretching  of  the  pelvic  tissues,  and  therefore  results  in  a  more  incom- 
plete involution  than  is  the  case  in  the  more  fortunate  woman  who  can  regulate 
her  life  to  her  condition. 

Heavy  work  soon  after  the  puerperium,  entailing  as  it  does  forcible  abdominal 
pressure,  is  also  a  factor.  It  is  possible  that  lack  of  nourishment  and  inter- 
current disease  may  have  a  deleterious  effect  on  the  supporting  tissues  during 
pregnancy  and  the  puerperium,  though  it  is  probable  that  they  do  not  in  the 
non-pregnant  state.  Long  lactation  periods,  such  as  poor  women  are  prone 
to  subject  themselves  to,  maj^  weaken  the  pelvic  structures  bj^  means  of  the 
local  atrophy  which  overlactation  produces  in  the  genital  system. 

Besides  the  damage  that  may  be  done  to  the  uterine  supports,  we  must  con- 
sider also  the  influence  which  pregnancy  exerts  on  the  musculature  of  the 
uterus.  It  has  been  shown  (Theilhaber)  that  when  the  uterus  develops  into 
maturity  the  proportion  of  muscular  tissue  to  connective  tissue  in  the  uterine 
wall  becomes  as  3  to  2  instead  of  2  to  3.  It  has  also  been  shown  that  each 
pregnancy  diminishes  the  relative  amount  of  muscular  fiber.  At  the  menopause 
the  uterus  becomes  atrophied,  chiefly  at  the  expense  of  the  musculature,  so  that 
the  connective-tissue  element  again  predominates. 

Repeated  pregnancies  may  by  their  influence  on  the  musculature  cause 
the  uterus  to  lose  its  proper  tone  so  that  it  becomes  flaccid.  This  flaccidity  is 
most  apparent  at  the  level  of  the  internal  os,  so  that  the  body  may  turn  on  the 
cervix  as  if  on  a  hinge.  Such  a  uterus  tends  to  sag  backward  away  from  the 
bladder  in  certain  positions  of  the  individual,  so  that  the  intestines  have  an 
opportunity  to  fall  into  the  utero vesical  space,  and,  by  exerting  pressure  on  the 
anterior  wall,  gradually  to  cause  a  retroflexion. 

After  the  menopause  the  uterus  is  always  in  the  second  degree  of  retro- 
version if  the  physiologic  process  of  atrophj^  takes  place  normally.  This  is  due 
to  the  change  in  the  musculature  of  the  uterine  wall.  The  uterus  loses  its  form 
of  angulation  and  the  body  becomes  smaller,  lighter,  and  more  flaccid.  It  sags 
away  from  the  bladder  and  the  intestines  enter  the  uterovesical  space.  The 
body  of  the  uterus,  however,  being  small  and  hght,  and  the  uterine  supports 
being  somewhat  shrunken,  complete  retroversion  does  not  take  place.  The 
uterus  remains  straight,  with  its  long  axis  pointing  in  the  direction  of  the  vagina 
and  Ijdng  among  the  intestines,  which  act  as  a  cushion  both  in  front  and  be- 
hind. It  is  important  to  remember,  therefore,  that  retroversion  of  the  senile 
uterus  is  physiologic  and  not  pathologic. 

In  nulliparous  women  lax  uterine  supports  that  allow  an  acquired  retro- 
version are  usually  the  manifestation  of  a  congenital  lack  of  tone  in  the  support- 
ing tissues.    This  tendency  may  be  confined  to  the  pelvis,  or  the  pelvic  condi- 


MALPOSITIONS  OF  THE  UTERUS  461 

tion  may  be  part  of  a  general  lack. of  tone  seen  elsewhere.  Women  who  have 
ptoses  of  the  various  abdominal  organs  are  very  apt  to  have  an  associated 
retroversion.  On  the  other  hand,  some  women  show  the  tissue  weakness  only 
in  relation  to  the  pelvic  organs.  In  the  latter  case  the  condition  may  be  one  of 
local  infantilism. 

The  mechanism  of  retroversion  in  women  with  congenitally  lax  tissues  is 
the  same  as  that  in  women  whose  supports  have  been  damaged  by  childbirth, 
namely,  a  sagging  backward  of  the  uterine  body  so  as  to  allow  the  intestines  to 
exert  pressure  on  the  anterior  surface. 

Congenital  insufficiencj"  may,  of  course,  act  in  combination  with  pregnancy 
to  produce  displacements  of  the  pelvic  organs,  as  we  have  already  seen. 

The  uterus  maj'  at  puberty  develop  in  the  position  of  retroversion,  and  when 
this  occurs  we  speak  of  the  condition  as  congenital  retroversion.  In  infancy 
and  childhood  the  uterus  is  always  retrocessed  and  it  may  be  retroverted. 
Congenital  retroversion  is,  therefore,  a  phase  of  infantilism.  There  are  usually 
other  manifestations  of  infantiUsm  in  association  with  retroversion,  such  as  a 
short  anterior  wall  of  the  vagina  and  short  uterosacral  ligaments. 

One  cause  of  congenital  retroversion  is  an  incomplete  descent  of  the  ovary. 
In  these  cases  the  infundibulopelvic  ligament  is  short,  and  by  dragging  back- 
ward on  the  uterus  prevents  a  normal  anteversion. 

Retrocession  may  be  the  result  of  lax  pelvic  supports'.  We  have  limited 
the  term  "retrocession"  to  the  condition  where  there  is  a  backward  position  of  the 
uterus  toward  the  hollow  of  the  sacrum,  but  where  the  uterine  body  retains  its 
anteflexed  relation  to  the  cervix.  Retrocession  may  be  the  result  of  the  injury 
of  childbirth  to  the  supporting  tissues,  but  it  is  more  commonly  a  manifestation 
of  infantilism,  and,  as  there  is  nearly  always  associated  with  it  abnormal  ante- 
flexion, the  subject  will  be  discussed  under  that  heading. 

It  should  be  noted  that  the  relaxation  of  pelvic  supports  with  consequent 
permanent  retroversion  is  not  the  result  of  ordinary-  falls  and  jars.  In  a  woman 
with  normal  pelvic  organs  nature  has  provided  for  accidents  of  this  kind.  Un- 
less a  woman  has  a  very  full  bladder,  the  sudden  increase  of  abdominal  pressure 
serves  only  to  force  the  uterus  into  its  normal  position.  If  the  bladder  is  full 
it  is  conceivable  that  the  uterus  might  be  forced  backward  from  the  bladder  by 
the  entrance  of  the  intestines  in  the  uterovesical  space.  Unless  the  force  is 
great  enough  to  cause  actual  destruction  of  the  tissues,  the  natural  elasticity  of 
the  uterus  and  its  supports  cause  it  to  return  immediately  to  its  normal  position. 
It  was  formerly  thought  that  various  forms  of  acquired  displacement,  such  as 
retroversion,  prolapse,  and  procidentia,  are  frequently  caused  by  falls  and  inju- 
ries, but  it  is  now  known  that  these  conditions  are  due  to  the  gradual  stretching 
of  supports  either  congenitally  weak  or  damaged  by  child-bearing. 

Pathologic  Conditions. — The  retroverted  uterus  following  child-bearing  is 
usually  large,  heavy,  and  congested  as  a  result  of  obstruction  of  the  circulation. 
The  uterine  vessels  enter  the  uterus  on  the  sides  at  a  right  angle.    Backward 


462  GYNECOLOGY 

rotation  of  the  organ,  therefore,  causes  a  torsion  in 'these  vessels  so  as  partially  to 
obstruct  the  veins.  The  circulation  from  the  ovarian  vessels  is  also  interfered 
with  by  the  downward  drag  of  the  ovaries  and  broad  ligaments.  The  enlarge- 
ment of  the  uterus  is  at  first  due  to  engorgement,  but  the  chronic  state  of  con- 
gestion may  result  in  a  permanent  hypertrophj^  of  the  uterine  wall. 

The  contour  of  the  congested  retrofiexed  uterus  is  often  somewhat  uneven, 
receiving  as  it  does  impressions  from  the  surrounding  surfaces  in  which  it  is  ' 
embedded,  and  has  a  deep  purple  mottled  color.  The  consistency  is  softer  and 
less  elastic  than  normal.  On  restoring  a  retrofiexed  uterus  to  its  proper  position 
during  an  abdominal  operation  it  is  often  possible  to  observe  a  very  marked 
change  take  place  in  a  few  minutes.  The  uterine  body  becomes  smaller  and 
firmer,  somewhat  erectile  in  consistency,  while  the  surface  becomes  smooth  and 
of  a  normal  pink  color.  The  endometrium  of  a  retroverted  uterus  usually  shows 
a  permanent  hypertrophy  which  is  like  that  of  the  phj^siologic  phases,  but  some- 
what more  marked.    This  is  doubtless  due  to  the  circulatory  disturbance. 

The  circulatory  change  caused  by  a  retrofiexed  uterus  is  shown  also  by  a 
dilatation  and  often  a  varicosity  of  the  pampiniform  plexus  of  veins  in  the 
broad  ligament.  This  condition  of  the  veins  is  an  important  factor  in  the 
symptomatology  of  retroversion-fiexion.  The  ovaries,  suspended  as  they  are 
from  the  posterior  wall  of  the  uterus,  share  in  the  retrodisplacement  and  lie  in 
the  lateral  culdesacs  of  the  pelvis  in  a  position  of  so-called  prolapse.  They 
are  also  apt  to  be  affected  by  the  obstructed  circulation.  The  physiologic  cystic 
degeneration  of  the  follicles  tends  sometimes,  though  not  always,  to  become 
exaggerated  beyond  the  normal  limits.  This  change  is  much  more  likely  to  occur 
if  the  ovary  is  immobilized  by  adhesions.  The  surfaces  of  ovaries  that  have 
been  long  prolapsed  sometimes  become  sclerotic,  owing  to  a  thickening  of  the 
albuginea. 

The  tubes  of  a  retrofiexed  uterus  often  appear  swollen  and  congested,  but 
permanent  changes  probably  do  not  occur  in  them  unless  they  become  adherent. 

The  question  as  to  whether  a  long-standing  retrofiexion  of  the  uterus  may 
result  in  traumatic  adhesions  is  one  about  which  there  has  been  a  considerable 
difference  of  opinion.  The  earlier  writers  accepted  the  possibility  and  fre- 
quency of  such  adhesions  almost  universally,  but  at  the  present  time  the  belief 
of  tjie  best  authorities  is  that  under  ordinary  conditions  they  rarely  occur  ex- 
cept as  a  result  of  infection.  There  is  no  doubt,  however,  that  pressure 
adhesions  on  the  posterior  surface  of  the  uterus  may  result  from  improperlj^ 
fitting  pessaries. 

The  question  of  traumatic  adhesions  from  retroversion  is  sometimes  a  matter 
of  considerable  importance,  especially  in  the  argument  of  medicolegal  cases. 
In  this  connection  it  might  be  remarked  that  it  is  difficult  to  see  why  the  poste- 
rior surface  of  the  uterus,  lying  in  contact  with  the  rectum,  should  become 
adherent  any  more  readily  than  does  the  anterior  surface  of  the  uterus  in  its= 
normal  contact  with  the  bladder. 


MALPOSITIONS    OF    THE    UTERUS  463 

Retroversion  of  the  uterus,  as  will  be  emphasized  later,  is  usually  the  first 
stage  of  descensus  or  prolapse.  In  fact,  it  may  be  said  that  a  retroverted 
uterus  from  relaxed  supports  is  always  in  a  greater  or  less  degree  of  prolapse,  a 
fact  which,  we  shall  see  later,  is  of  the  very  greatest  importance  in  relation  to 
the  symptomatology  and  treatment. 

Sjnnptoms  of  Retroversion  Due  to  Relaxation. — Some  women  with  even 
marked  degrees  of  retroversion  exhibit  no  symptoms  whatever.  This  fact  has 
led  some  to  infer  that  the  backward  displacement  of  the  uterus  is  physiologic 
(Cabot).  Such  observations  are  erroneous,  for  there  can  be  no  doubt  that  the 
great  majority  of  women  with  retroversion  suffer  in  some  way  from  the  condi- 
tion. The  two  most  common  symptoms  directly  caused  by  retroversion  are 
backache  and  the  sense  of  pelvic  pressure. 

In  the  analysis  of  a  series  of  500  cases  of  retroversion  from  all  causes  the 
writer  found  that  sacral  backache  was  a  definite  symptom  in  76  per  cent.  The 
cause  of  backache  as  a  result  of  backward  rotation  of  the  uterus  has  not  been 
satisfactorily  explained,  and  for  that  reason  its  existence  as  a  definite  symptom 
of  retroversion  has  been  denied  (Cabot) . 

The  confusion  that  has  arisen  in  this  subject  is  partly  due  to  the  supposition 
that  retrodisplacements  may  cause  backaches  at  any  level  of  the  spine.  It 
should  be  remembered  that  backache  from  retroversion  occurs  only  in  the  sacral 
or  very  low  lumbar  region  and  is  always  central.  Of  the  fact  that  retroversion 
of  the  uterus  does  cause  backache  in  this  location  there  is  no  doubt  whatever. 

The  nature  of  the  pain  is  not  entirely  characteristic.  It  is  often  worse,  on 
exertion  or  standing.  Sometimes  it  is  worse  at  night.  It  is  often  difficult  to 
differentiate  it  from  sacro-iliac  or  muscular  strain. 

The  sense  of  pelvic  pressure  may  be  combined  with  a  sacral  backache  or  it 
may  exist  as  a  sjmaptom  by  itself.  This  symptom  is  the  result  partly  of  the 
increased  weight  of  the  uterus,  but  is  chiefly  due  to  its  condition  of  prolapse. 
It  may  appear  as  a  definite  bearing-down  feeling  which  is  increased  or  brought 
on  by  standing,  or  it  may  manifest  itself  as  an  early  state  of  tire  on  exertion. 

The  physical  exhaustion  resulting  from  retroversion  and  prolapse  has  a  very 
important  influence  on  the  general  health  of  the  patient,  and  especially  on  the 
nervous  system.  It  is  the  commonest  occurrence  to  see  active,  athletic,  good- 
tempered  women  after  several  childbirths  become  nervous,  irritable,  unreason- 
able, discontented,  easily  exhausted,  and  apparently  completely  changed,  both 
nervously  and  physically,  as  a  result  of  the  constant  pelvic  discomfort  and  weak- 
ness from  retroversion  and  prolapse.  There  may  be  numerous  secondary  symp- 
toms that  develop  from  the  general  nervous  disturbance,  such  as  headaches, 
muscle  pains,  indigestion,  constipation,  etc.,  which  are  to  be  regarded  as  indi- 
rectly caused  by  retroversion  of  the  uterus. 

Patients  with  retrodisplacement  frequently  complain  of  pain  in  one  or  both 
sides.  When  pelvic  inflammation  is  not  present  these  pains  are  commonly 
assigned  to  the  ovaries.    Some  even  speak  of  an  ovarian  neuralgia,  others  ascribe 


464  GYNECOLOGY 

the  pain  to  the  cystic  degeneration  of  the  ovaries.     The  pain  is  probably  due 
usually  to  the  varicose  condition  of  the  veins  of  the  broad  ligament. 

Patients  with  retroversion  in  about  56  per  cent,  of  cases  suffer  some  dis- 
turbance of  the  menstrual  function  (author's  figures).  A  secondary  dysmenor- 
rhea is  often  present,  manifested  by  an  exaggeration  of  the  symptoms  that 
occur  during  the  intermenstrual  period.  Thus,  backache,  pelvic  pressure,  pain, 
in  the  side  are  increased  during  catamenia,  as  are  all  the  nervous  and  general 
and  constitutional  symptoms. 

Patients  with  congenital  retroflexion  usually  suffer  from  essential  dysmenor- 
rhea, the  pain  often  being  located  in  the  back  instead  of  in  the  abdomen.  True 
dysmenorrhea  is  more  common  in  backward  displacements  when  there  is  also 
flexion.  Abnormalities  in  the  menstrual  flow  are  not  infrequent,  though  not 
constant.  Owing  to  the  obstruction  of  the  circulation  and  the  permanent 
hypertrophy  of  the  endometrium  that  are  common  in  the  retroverted  uterus, 
various  degrees  of  menorrhagia  are  encountered. 

Irregularity  in  the  time  of  the  intermenstrual  periods  is  apt  to  exist,  the 
irregularity  consisting  usually  in  a  too  frequent  incidence  of  the  menses. 

Leukorrhea  is  often  present  as  a  result  of  a  hypersecretion  of  the  congested 
endometrium. 

Constipation  is  present  in  about  51  per  cent,  of  cases  (author's  figures). 
This  may  possibly  be  due  to  partial  obstruction  of  the  rectal  lumen,  but  it  is 
more  probable  that  the  pressure  of  the  uterine  body  on  the  wall  of  the  rectum 
interferes  with  the  normal  muscular  movements  of  the  gut,  thus  diminishing 
its  expulsive  force. 

Retroversion  is  said  to  cause  symptoms  of  irritable  bladder  by  a  backward 
pull  on  the  bladder  wall.  This  is  probably  not  true.  The  bladder  is  an  extra- 
ordinarily adaptable  organ,  and  when  one  considers  abnormal  positions  in  which 
it  can  be  placed  without  symptoms  during  various  reconstructive  operations 
it  is  difficult  to  believe  that  the  slight  traction  exerted  by  a  retroposed  uterus 
could  cause  definite  symptoms  of  irritability.  Irritable  bladder  is  frequently 
caused  by  childbirth,  and  may  thus  be  associated  later  with  a  retroversion, 
without  causal  relation  between  the  two  conditions. 

Retroversion  is  a  not  uncommon  cause  of  abortion.  This  may  be  due  to  the 
permanent  hypertrophy  of  the  endometrium,  which  offers  a  poor  soil  for  the 
growth  of  the  ovum,  or  it  may  possibly  be  referred  to  the  imperfect  circulation 
of  the  maternal  blood  through  the  uterus.  Impaction  of  the  pregnant  uterus  in 
the  pelvis  may  cause  abortion  as  a  result  of  interference  with  the  growth  of  the 
uterine  musculature. 

Women  with  retroversion  are  apt  to  be  sterile,  especially  those  in  whom  the 
retroversion  is  due  to  congenitally  weak  supports. 

In  women  with  retroversion  acquired  from  childbirth  the  sterility,  if  present, 
is  probably  the  result  of  the  displacement  of  the  cervix  which  no  longer  dips 
into  the  receptaculum  seminis.     In  women  with  naturally  insufficie^  supporting 


MALPOSITIONS    OF    THE    UTERUS  465 

tissue  the  same  cause  may  act,  but  there  are  also  apt  to  be  other  manifestations 
of  infantiUsm  which  may  combine  to  prevent  fertility.     (See  Sterility.) 

The  diagnosis  of  retroversion  and  retroversion-flexion  is  usually  a  simple 
matter,  and  skill  can  be  acquired  with  comparatively  short  experience.  If  the 
touch  is  gentle,  so  as  not  to  cause  pain  and  resistance  on  the  part  of  the  patient, 
it  is  rarely  necessary  to  use  an  anesthetic.  The  method  of  using  a  uterine  sound 
or  probe  is  obsolete,  unsurgical,  and  dangerous.  Examination  is  much  more 
accurate  with  the  patient  on  a  table  than  on  a  bed.  It  is  very  important  that 
the  bladder  should  be  emptied  immediately  before  the  examination,  as  a  full 
bladder  may  cause  a  considerable  degree  of  backward  rotation.  The  position 
of  the  uterus  can  be  diagnosed  entirely  by  bimanual  examination,  inspection 
of  the  cervix  giving  no  additional  evidence  of  value. 

Retroversion  of  the  first  degree  is  determined  by  the  external  hand  on  the 
abdomen,  which  feels  the  fundus  pointing  away  from  the  bladder. 

In  retroversion  of  the  second  degree  the  fundus  of  the  uterus  cannot  be  felt 
either  by  the  abdominal  hand  or  b}'  the  internal  vaginal  finger.  The  cervix  is 
found  pointing  in  the  direction  of  the  long  axis  of  the  vagina.  In  retroversion 
of  the  third  degree  the  posterior  wall  of  the  uterus  can  be  felt  by  the  vaginal 
finger  dipping  backward  into  the  culdesac  of  Douglas.  If  there  is  retroflexion 
the  angle  between  body  and  cervix  is  readily  felt.  In  third  degree  retroversion 
and  flexion  the  cervix  points  either  in  the  direction  of  the  axis  of  the  vagina  or 
forward  toward  the  anterior  vaginal  wall. 

One  of  the  commonest  errors  in  diagnosis  is  to  mistake  an  anteflexion  with 
retrocession  for  retroversion.  The  cervix  of  anteflexion  points  in  the  same 
direction  as  that  of  a  retroversion,  and  as  the  posterior  wall  of  the  cervix  in 
these  cases  is  often  abnormally  long  it  may  be  mistaken  for  the  posterior  wall 
of  the  uterus.  The  error  is  still  further  facihtated  by  the  fact  that  when  ante- 
flexion and  retrocession  are  present  the  fundus,  though  pointing  forward  in  its 
relation  to  the  cervix,  cannot  always  be  felt  by  the  external  abdominal  hand. 
The  anterior  angle  between  the  fundus  and  cervix,  however,  can  always  be  made 
out  by  the  vaginal  finger  feeling  along  the  anterior  cervical  wall.  If  this  pre- 
caution be  taken  the  mistake  need  never  be  made. 

If  the  hymen  is  very  tight  it  is  sometimes  necessary  to  make  a  bimanual 
rectal  examination.  This  requires  more  skill  than.dops  a  vaginal  examination. 
With  the  finger  in  the  rectum  the  cervix  feels  very  much  larger  than  it  does  per 
vaginam,  and  it  is  frequently  diagnosed  as  a  pelvic  tumor  by  the  inexpert.  With 
the  finger  in  the  rectum  the  uterus  can  be  perfectly  well  felt  bimanualh^,  but, 
on  account  of  the  indistinctness  with  which  the  cervix  is  felt,  it  is  sometimes 
difficult  to  tell  which  is  the  fundus  and  which  is  the  cervix.  One  is,  therefore, 
sometimes  in  doubt  after  rectal  examination  whether  the  uterus  is  in  the  normal 
position  of  anteversion  or  in  the  third  degree  of  retroversion-flexion. 

The  fundus  of  a  large  uterus  sharply  retroflexed  is  often  mistaken  for  a 
myoma  growing  centrally  on  the  posterior  wall,  and  vice  versa. 

30 


466  GYNECOLOGY 

Treatment. — When  a  retroverted  uterus  causes  no  symptoms  there  is  no 
need  of  treating  it. 

When  a  retroverted  uterus  gives  no  symptoms,  but  there  is  an  associated 
sterihty  or  tendency  to  abortion,  treatment  is  indicated. 

When  retroversion  definitely  causes  symptoms,  treatment  is  advisable. 

The  treatment  of  retroversion  due  to  relaxation  consists  in  restoring  the 
uterus  to  its  normal  position,  and  this  can  be  done  by  orthopedic  or  surgical 
measures.  Orthopedic  measures  comprise  the  various  forms  of  rings  and  pes- 
saries apphed  in  the  vagina  to  support  the  uterus  from  below,  while  surgical 
treatment  includes  numerous  operative  procedures  for  suspending  the  uterus 
from  above. 

Pessaries  are  of  considerable  value  in  the  treatment  of  retrodisplacements 
with  prolapse,  but  for  uncomplicated  retroversion  they  have  only  a  Hmited 
field  of  usefulness,  excepting  as  a  temporary  palhative  measure.  Occasionally 
women  wear  pessaries  for  years  without  discomfort,  but,  as  a  rule,  they  become 
a  source  of  annoyance  in  a  comparatively  short  time.  They  require  constant 
attention  in  order  to  keep  them  clean,  and  even  when  properly  cared  for  cause  a 
mild  vaginal  irritation.  If  they  are  neglected  or  if  they  fit  improperly,  they 
may  cause  severe  ulceration  and  vaginitis.  The  long-continued  wearing  of  a 
pessary  acts  as  a  nervous  irritant,  and  patients  with  a  tendency  to  pelvic  neuroses 
are  made  worse  by  their  use. 

Pessaries  keep  the  uterus  forward  by  pressure  on  the  posterior  wall  of  the 
cervix  near  the  internal  os.  If  the  tone  of  the  musculature  has  been  damaged, 
so  that  the  uterus  is  retroflexed,  the  pessary  exerts  its  force  directly  at  the 
point  of  flexion,  and  consequently  aggravates  the  condition.  Pessaries  should 
never  be  used,  therefore,  when  retroflexion  is  present. 

Pessaries  are  most  valuable  in  treating  retroversion  during  the  early  months 
of  pregnancy  and  immediately  after  the  puerperium.  A  lax  retroverted  uterus 
that  becomes  pregnant  is  in  serious  danger  of  aborting.  Such  a  position  produces 
pelvic  pressure  and  is  a  frequent  cause  of  so-cafled  reflex  vomiting.  The  apphca- 
tion  of  a  pessary  which  holds  the  uterus  in  its  normal  position  until  the  fourth 
month,  when  it  rides  above  the  pelvis,  will  often  avert  the  danger  of  abortion 
and  relieve  the  symptoms  of  pressure  and  nausea. 

If  after  the  puerperium  it  is  found  that  the  uterus  is  subinvoluted  and 
tends  to  sag  backward,  a  permanent  retroversion  may  often  be  prevented  by 
the  use  of  a  pessary  until  the  uterus  attains  a  normal  size  and  consistency. 

For  most  cases  of  retroversion  that  give  symptoms  surgical  treatment 
is  the  most  satisfactory.  At  the  present  day  this  usually  involves  opening  the 
abdomen  and  employing  one  of  the  many  methods  devised  for  maintaining 
the  uterus  in  its  forward  position..  The  technical  details  of  the  best  of  these 
operations  are  described  in  the  section  on  Surgery.  We  shall  discuss  here  some 
of  the  principles  underlying  those  operations.  In  the  days  when  opening  the 
abdominal  cavity  was  a  dangerous   procedure   the   Alexander   operation  was 


MALPOSITIONS    OF    THE    UTERUS  467 

devised.  This  consists  in  exposing  the  inguinal  canals  by  two  incisions  and 
drawing  on  the  round  ligaments  until  the  uterus  is  brought  to  a  forward  position. 
The  slack  of  the  round  ligaments  is  either  removed  or  sewed  in  the  inguinal 
wounds.  By  this  operation  the  abdominal  cavity  need  not  be  opened  and  the 
danger  of  peritonitis  is  avoided.  It  is  also  a  safe  procedure  with  reference  to 
future  childbirth.  The  operation  at  present  is  comparatively  httle  used  in 
this  country,  as  it  has  numerous  disadvantages.  It  is  often  difficult  to  find 
the  ligaments  in  the  inguinal  canals;  small  undeveloped  ligaments  break  off 
easily  during  the  process  of  drawing  them  out  of  the  abdomen;  if  undetected 
pelvic  adhesions  exist,  the  operation  is  entirely  nullified;  it  is  impossible 
adequately  to  inspect  the  pelvic  organs,  and,  most  important  of  all,  the 
percentage  of  recurrence  is  very  high  as  compared  with  that  of  other 
operations. 

Abdominal  operations  consist  of  various  surgical  devices  by  which  either 
the  uterus  is  attached  to  the  anterior  abdominal  wall  or  its  hgaments  are  em- 
ployed so  as  to  provide  a  new  and  artificial  support. 

Operations  for  attaching  the  uterus  bodily  to  the  anterior  abdominal  wall 
are  called  ventral  suspension  and  ventral  fixation.  These  two  terms  are  some- 
what vaguely  used,  but  at  the  time  when  the  operations  were  popular  ventral 
suspension  implied  that  the  uterus  was  sewed  to  the  peritoneum  only,  while 
fixation  meant  that  the  supporting  sutures  passed  through  peritoneum,  muscle, 
and  fascia.  The  first  of  these  operations  often  resulted  in  drawing  the  perito- 
neum out  into  long  filiform  bands,  and  has  been  entirely  discarded.  The  second 
operation  of  fixation,  when  thoroughly  done,  resulted  in  too  firm  an  adhesion 
of  the  uterus  to  the  abdominal  wall,  causing  symptoms  of  local  discomfort  and 
occasional  dystocia.  This  operation  has  also  been  given  up  except  in  some 
cases  of  prolapse  in  women  beyond  the  child-bearing  period. 

Another  type  of  operation  comprises  the  principle,  introduced  by  Gilliam,  of 
drawing  a  loop  of  each  broad  hgament  through  the  abdominal  wall  at  some 
point.  The  number  of  modifications  of  this  operation  is  very  great,  as  will  be 
seen  by  referring  to  the  section  on  Surgery,  where  the  details  of  the  most  im- 
portant are  described.  Operations  performed  by  the  Gilliam  method  are  very 
efficient  in  maintaining  the  position  of  the  uterus,  the  percentage  of  recurrences 
being  almost  negligible  even  after  childbirth.  There  are  some  objections  to  the 
operation.  It  is  not  always  possible  to  control  exactly  the  position  of  the 
uterus  on  account  of  the  variation  in  the  site  of  the  natural  attachment  of  the 
round  ligaments  to  the  uterus.  If  the  attachment  is  low,  drawing  the  liga- 
ments tightly  through  the  abdominal  wall  faces  the  uterus  too  much  toward  th'e 
abdominal  wall,  and  causes  a  retrofiexion  of  the  body  at  the  same  time.  This 
position  is  too  far  from  the  normal  and  sometimes  gives  trouble.  If  the  uterus 
is  drawn  up  too  tightty,  as  it  is  liable  to  be  by  this  operation,  the  ovaries  and 
tubes  are  brought  to  too  high  a  level,  and  may  become  involved  in  postoperative 
adhesions  near  the  abdominal  wall.     The  operation  is  also  liable  to  result  in 


468  GYNECOLOGY 

creating  a  diaphragm  across  the  pelvis  consisting  of  uterus  and  broad  ligaments. 
This  has  been  known  to  result  in  serious  dystocia. 

Another  type  of  operation  has  for  its  principle  the  reduplication  of  the  sup- 
porting ligaments  without  making  artificial  suspensory  attachments.  The 
earliest  of  these  operations  consisted  in  a  simple  reduplication  of  the  round 
ligaments.  The  principle  of  this  operation  is  hke  that  of  Alexander's,  except 
that  the  shortening  of  the  ligaments  is  done  intra-abdominally.  This  method 
of  support  is  extremely  inefficient,  and  is  followed  by  a  large  percentage  of 
recurrences.  A  more  efficient  operation  of  this  type  is  the  so-called  "Webster- 
Baldy  operation,"  by  which  the  round  ligaments  are  drawn  backward  through 
an  artificial  opening  in  the  broad  ligaments  and  attached  to  each  other  on  the 
posterior  wall  of  the  uterus.  This  brings  the  uterus  into  a  more  nearly  normal 
position  than  does  any  other  operation  yet  devised,  and  is  indicated  in  many 
cases  of  uncomplicated  retroversion.  If,  however,  there  is  much  prolapse  or  the 
uterus  is  heavy,  or  there  is  liability  of  postoperative  adhesions,  the  results  of 
this  operation  are  not  uniformly  good. 

Another  operation  of  the  reduplicating  type  is  that  devised  by  Coffey,  by 
which  the  broad  ligaments  are  folded  in  together  in  front  of  the  uterus.  The  results 
of  this  operation  are  not  entirely  satisfactory  and  it  has  a  limited  field  of  usefulness. 

The  operation,  suggested  many  years  ago  bj^  Olshausen,  is  one  of 'the  simplest 
and  most  efficacious  of  all  the  various  procedures,  and  is  applicable  to  all  forms 
of  retrodisplacement.  By  this  operation  a  single  ligature  is  passed  around  each 
round  ligament,  near  the  uterus  and  through  the  peritoneum,  rectus  muscle, 
and  fascia.  The  ligatures  are  tied  very  tightly,  so  as  to  create  a  small  ligamentous 
adhesion  between  the  round  ligament  and  the  abdominal  wall.  By  varying  the 
distance  of  the  ligature  from  the  uterine  body  and  the  point  of  attachment  on 
the  abdominaFwall  the  desired  position  of  the  uterus  can  be  exactly  determined. 
The  results  of  this  operation  if  properly  done-  are  almost  constant,  and  the  dis- 
advantages mentioned  in  reference  to  the  other  operations  are  practically  ob- 
viated. The  operation  is  also  applicable  to  conditions  of  prolapse  excepting 
severe  procidentia.    The  results  as  regards  child-bearing  are  most  satisfactory. 

In  all  operations  in  which  the  uterus  is  suspended  from  the  abdominal  wall, 
except  in  Sim.pson's  and  Mayo's  modification  of  the  Gilliam  method,  the 
possibility  of  intestinal  obstruction  cannot  be  absolutely  ruled  out.  If  the  opera- 
tions are  properly  performed  the  possibility  is  exceedingly  remote,  except  in 
the  now  obsolete  ventral  suspension,  with  its  resultant  filiform  band. 

Some  prefer  reposition  of  the  uterus  by  the  vaginal  route. 

A  method  for  vaginal  fixation  is  described  in  Part  III. 

RETROVERSION  DUE  TO  ADHESIONS 

Adherent  retroversion  is  a  result  of  pelvic  peritonitis,  the  most  common 
causes  of  which  are  gonorrhea,  puerperal  infection,  and  tuberculosis.  An  addi- 
tional cause  is  the  pelvic  extension  from  an  acute  appendicitis,  especially  when 


MALPOSITIONS    OF    THE    UTERUS  469 

the  attack  occurs  in  young  girls.  Retracting  adhesions  may  also  be  due  to 
improperly  fitting  pessaries.  As  has  already  been  explained,  the  exudate  of  a 
pelvic  peritonitis  settles  by  gravity  in  the  posterior  culdesac,  and  the  drying 
and  organization  of  the  exudate  results  in  adhesions  of  the  posterior  surfaces  of 
the  uterus  and  adnexa.  The  shrinking  of  these  adhesions  draws  the  uterus  back- 
ward into  the  position  of  retroversion  or  flexion. 

Adherent  retroversion  differs  from  the  retroversion  of  relaxation  in  that 
there  is,  as  a  rule,  no  descensus  or  prolapse.  In  fact,  the  uterus  is  held  more 
or  less  rigidly  at  its  normal  level  by  the  pelvic  adhesions.  This  fact,  as  we  shall 
see  later,  is  a  matter  of  clinical  importance. 

The  pathologic  anatomy  of  adherent  retroversion  is  that  of  pelvic  inflam- 
mation, and  has  already  been  described  in  the  section  devoted  to  that  subject. 

The  diagnosis  of  adherent  retroversion  is  not  always  an  easy  matter.  When 
an  obvious  inflammation  of  the  adnexa  is  present,  it  is  known  that  the  retro- 
verted  uterus  must  share  in  the  general  inflammatory  process,  and  is,  therefore, 
probably  adherent.  It  may  be  that  the  inflammation  of  the  adnexa  has  sub- 
sided to  such  an  extent  that  they  cannot  be  palpated.  In  this  case  it  is  diffi- 
cult to  differentiate  an  adherent  retroversion  from  an  impacted  non-adherent 
retroversion. 

Sometimes  the  uterus  becomes  attached  to  the  rectum  in  such  a  way  as  to 
allow  considerable  mobility,  even  to  the  extent  that  the  displacement  may  be 
partially  reduced  by  bimanual  examination.  Under  these  circumstances  an 
error  in  diagnosis  may  readily  be  made,  and  such  an  error  might  be  more  or  less 
serious  if  Alexander's  operation  or  the  application  of  a  pessary  were  being 
contemplated. 

When  no  evidence  of  adnexal  disease  is  made  out,  the  presence  of  adhesions 
can  usually  be  detected  by  the  pain  that  is  elicited  when  the  uterus  is  drawn 
away  from  the  rectum  by  the  examining  finger  placed  behind  the  cervix. 

The  symptomatology  of  adherent  retroversion  is  identical  with  that  of 
pelvic  inflammation.  Backache  and  pelvic  pressure  symptoms  are  less  pro- 
nounced than  in  retroversion  from  relaxation,  because,  as  a  rule,  there  is  little 
or  no  descensus  of  the  uterus. 

The  treatment  of  adherent  retroversion  is  included  in  that  of  pelvic  inflam- 
mation. In  choosing  the  best  method  of  replacing  the  uterus  one  must  consider 
the  possible  effect  of  postoperative  adhesions.  Operations  of  the  reduplicating 
type,  such  as  Coffey's  and  Baldy's,  do  not  lift  the  uterus  sufficiently  away  from 
the  posterior  culdesac,  so  that  adhesions  more  readily  form.  Moreover,  these 
operations  do  not  give  sufficient  supporting  power  to  insure  resistance  against 
the  contraction  of  new  adhesions. 

Experience  has  shown  that  operations  of  the  GilHam  type,  performed  for 
adherent  retroversion,  are  sometimes  followed  by  very  extensive  adhesions. 

The  most  satisfactory  operation  for  the  avoidance  of  troublesome  postopera- 
tive adhesions  is  Olshausen's  anterior  fixation  of  the  round  ligaments. 


470  GYNECOLOGY 

RETROVERSION  DUE  TO  DISPLACEMENT  BY  TUMORS 

The  uterus  is  less  commonly  displaced  backward  by  tumors,  for  the  majority 
of  pelvic  tumors  lie  in  the  posterior  culdesac  and  tend  to  force  the  uterus  up- 
ward and  forward. 

Pedunculated  fibroids  growing  from  the  anterior  uterine  wall  may  cause 
retroversion,  as  may  ovarian  tumors  with  long  pedicles  which  occasionally  rest 
in  the  uterovesical  space.  On  rare  occasions  pus-tubes  become  adherent  to  the 
anterior  wall  and  force  the  uterus  backward  as  they  develop. 

A  uterus  that  has  been  forced  back  by  a  tumor  will  sometimes  spring  back 
spontaneously  to  its  normal  position  after  removal  of  the  tumor,  even  when  the 
displacement  has  been  maintained  for  a  considerable  length  of  time.  As  a 
rule,  however,  the  retroversion  is  permanent,  and  the  removal  of  tumors  that 
dislocate  the  uterus  should  always  be  followed  by  a  proper  supporting  opera- 
tion. 

PROLAPSE  AND   PROCIDENTIA 

PROLAPSE 

Prolapse  of  the  uterus  is  usually  a  second  phase  of  retroversion  as  a  result  of 
relaxation,  and  its  causes  are  the  same,  namely,  child-bearing  and  physiologic 
insufficiency  of  tissues.  Occasionally  prolapse  is  the  result  of  downward  pres- 
sure from  an  abdominal  tumor  or  from  ascites.  In  the  very  great  majority  of 
cases,  however,  prolapse  is  the  result  of  child-bearing,  and  is  far  more  frequent 
than  is  commonly  supposed.  It  is  almost  constantly  associated  to  a  greater  or 
less  degree  with  vaginal  relaxation,  and  is  a  factor  to  be  reckoned  with  in  all 
reconstructive  surgery  for  the  repair  of  injuries  due  to  childbirth. 

As  has  been  stated  in  the  definition,  prolapse  relates  to  all  forms  of  descensus 
from  the  normal  level  of  the  uterus  to  a  point  where  the  cervix  reaches  the 
vaginal  introitus.  Under  normal  conditions  the  uterus  possesses  some  mobility 
in  the  direction  of  the  pelvic  outlet,  and  under  the  influence  of  forced  abdominal 
pressure  there  is  a  certain  amount  of  physiologic  descensus.  The  uterus,  how- 
ever, should  return  immediately  to  its  normal  position  after  release  of  the  ab- 
dominal pressure.  The  normal  excursion  of  the  uterus  varies  somewhat  in 
individuals.  Descensus  is  pathologic  when  it  exceeds  the  normal  Hmits,  or 
where,  after  the  continued  abdominal  pressure  of  standing,  walking,  working, 
etc.,  the  uterus  does  not  return  to  its  physiologic  level. 

Prolapse  is  in  most  cases  associated  with  retroversion,  to  which  it  is  a  second- 
ary stage  in  the  process  of  pelvic  relaxation.  It  may,  however,  exist  with  the 
body  of  the  uterus  in  the  forward  position.  The  entire  uterus  may  sag  downward 
toward  the  pelvic  outlet  without  changing  the  direction  of  its  craniocaudal  axis, 
or  the  fundus  may  remain  in  normal  position  while  the  cervix  swings  forward 
toward  the  bladder.     The  latter  condition  is  due  to  abnormally  lax  uterosacral 


MALPOSITIONS    OF    THE    UTERUS 


471 


ligaments.     This  form  of  prolapse  may  occur  after  an  anterior  suspension  of  the 
uterus. 

Prolapse  is  associated  with  most  cases  of  relaxation  of  the  vaginal  walls, 
especially  with  the  anterior  wall,  for,  on  account,  of  the  intimate  attachment 
of  the  bladder  to  the  cervix,  prolapse  naturally  drags  the  bladder  down  with  it 
and  favors  the  formation  of  a  cystocele.  Per  contra,  the  presence  of  a  cystocele 
usually  indicates  an  associated  prolapse.     However,  the  two  conditions  do  not 


Cvv^ocele.  lbfc<,)[vv-\uinQ'' 


^^^.Sxcx\j«:s 


vxvcv  wx- 


FiG.  195. — Retroversion  and  Descensus  of  the  Uterus  Toward  the  Vaginal  Orifice. 
The  vaginal  walls  are  relaxed,  with  prolapse  of  bladder  and  rectum  (cystocele  and  rectocele). 


necessarily  go  hand  in  hand,  for  cystocele  is  occasionally  found  without  pro- 
lapse, especially  when  it  occurs  in  nulliparous  women. 

Prolapse  may  be  present  with  anteflexion  in  those  cases  in  which  the  ante- 
flexion exists  in  combination  with  retrocession.  In  fact,  retrocession  implies 
a  certain  degree  of  prolapse.  This  subject  will  be  discussed  under  the  heading 
of  Anteflexion. 

Diagnosis. — The  existence  of  a  prolapse  is  often  sufficiently  evident  from  a 

history  of  pelvic  pressure,  especially  if  the  symptoms  date  from  childbirth, 

,  The  diagnosis  is  made  in  the  dorsal  position  by  placing  the  examining  finger  on 


472  GYNECOLOGY 

the  cervix  and  requesting  the  patient  to  bear  down,  as  in  the  act  of  defecation, 
when  the  downward  excursion  of  the  uterus  may  be  noted.  It  is  sometimes 
difficult  to  get  a  patient  to  exert  abdominal  pressure  in  this  way,  and  it  is  then 
necessary  to  make  the  examination  with  the  patient  in  the  standing  position. 

In  both  tests  there  may  be  an  error,  for  the  amount  of  prolapse  in  the  same 
patient  is  not  always  constant.  After  fatigue  from  long  standing  the  uterus 
may  be  several  degrees  lower  than  after  rest  in  bed.  It  is  important  to  know 
the  lowest  point  to  which  the  uterus  may  descend.  Another  error  is  sometimes 
made  in  examining  a  patient  from  whom  a  pessary  has  just  been  removed,  for 
the  prolapse  may  not  become  evident  until  the  patient  has  been  about  on  her 
feet  for  some  time. 

Very  often  the  full  extent  of  the  prolapse  is  not  apparent  until  the  patient 
is  anesthetized  and  the  cervix  is  drawn  downward  toward  the  vaginal  outlet. 
In  determining  the  degree  of  prolapse  with  the  patient  under  anesthesia  it  is 
important  to  be  familiar  with  the  amount  of  downward  traction  that  the  normal 
uterus  will  undergo.  This  varies  in  different  women  and  is  sometimes  con- 
siderable.. 

Symptoms. — The  symptomatology  of  prolapse  has  already  been  described 
under  Retroversion,  for  it  is  the  descensus  which  almost  necessarily  accompanies 
retroversion  that  causes  the  most  important  symptom,  pelvic  pressure,  with  its 
train  of  nervous  and  constitutional  complaints. 

The  severity  of  the  pressure  symptoms  does  not  necessarily  correspond  to 
the  amount  of  prolapse,  for  some  women  with  very  marked  descensus,  even  to 
the  degree  of  procidentia,  suffer  little  or  no  discomfort,  while  in  others  very 
moderate  prolapse  may  cause  distressing  results.  These,  how^ever,  are  the  ex- 
ceptions, and,  as  a  rule,  the  relationship  between  the  symptomatology  and  the 
anatomic  position  of  the  uterus  is  fairly  constant. 

It  is  important  to  remember  that  in  patients  suffering  from  the  lacerations 
of  childbirth  the  symptoms  of  pelvic  pressure  and  weakness  are  due  chieflj^  to 
the  descent  of  the  uterus  and  not  to  the  tears  of  the  cervix  and  perineum.  This 
significant  fact  is  referred  to  again  under  the  subject  of  Lacerations. 

Treatment. — Prolapse  of  the  uterus  may  be  treated  palliatively  ^dth  vaginal 
supports  or  radically  by  surgical  operation. 

The  application  of  vaginal  tampons  gives  temporary  relief,  but  the  long- 
continued  use  of  tampons  is  undesirable.  In  prolapse  pessaries  have  a  wider 
field  of  usefulness  than  in  uncomplicated  retroversion.  They  are  of  especial 
advantage  in  treating  elderly  women  with  uterine  atrophy,  in  whom  there  is 
some  contra-indication  to  surgical  operation.  In  prolapse  of  the  pregnant 
uterus  pessaries  are  an  absolute  necessity.  In  women  of  the  child-bearing  period 
who  wish  more  children  before  going  through  a  radical  reconstructive  operation 
they  are  also  valuable. 

Pessaries  relieve  prolapse  by  sustaining  the  vault  of  the  vagina  and  by 
stretching  out  the  vaginal  walls  so  as  to  take  up  the  slack  caused  by  their  relaxa- 


MALPOSITIONS    OF    THE    UTERUS  473 

tion.     The  counter-support  of  the  pessary  is  against  the  two  columns  of  the 
arch  of  the  pubes. 

If  the  pessary  causes  a  retroflexion  of  the  uterus  this  form  of  treatment  is 
contra-indicated.  In  women  after  the  menopause  with  genital  atrophy  the 
uterus  gives  no  trouble,  for  it  is  not  large  or  heavy  enough  to  become  retro- 
flexed  over  the  upper  pole  of  the  support.  Pessaries  are,  therefore,  much  more 
appUcable  to  elderly  women  than  during  the  child-bearing  period. 

In  using  pessaries  after  the  menopause  it  is  important  to  pay  special  attention 
to  cleanhness  by  douching  and  occasionally  removing  and  scrubbing  the  pessary. 
The  senile  vaginal  membrane  is  thin,  easily  excoriated,  and  prone  to  plastic 
inflammation,  and  pessaries  are  apt  to  become  covered  with  irritating  incrusta- 
tions deposited  from  the  vaginal  secretions. 

It  is  best  when  possible  to  use  hard-rubber  pessaries,  especially  in  elderly 
women,  as  the  soft-rubber  varieties  become  very  foul  even  with  careful  attention. 

Moderate  degrees  of  prolapse  are  sometimes  spontaneously  cured  by  atrophy 
and  shrinking  of  the  parts  after  the  menopause.  This  spontaneous  cure  is, 
however,  not  to  be  rehed  upon,  for  more  often  the  symptoms  of  prolapse  are 
increased  after  the  menopause  is  estabUshed. 

Surgical  Treatment.— When  surgery  is  feasible,  operative  measures  for  pro- 
lapse are  usually  to  be  recommended,  for  in  this  way  alone  can  the  patient  be 
radically  cured.  As  prolapse  is  usually  one  of  several  manifestations  of  damage 
done  by  child-bearing,  its  treatment  is  in  most  cases  only  one  of  several  proced- 
ures, each  one  of  which  is  necessary  for  the  complete  cure  of  the  patient.  One 
or  more  of  the  foUoAving  conditions  may  be  present :  lacerated  cervix,  cystocele, 
lacerated  perineum,  and  diastasis  of  the  abdominal  recti  muscles.  Of  all  these, 
prolapse  is  the  most  important,  for  it  is  conducive  of  the  most  serious  symptoms. 

The  methods  of  treating  the  other  injuries  of  childbirth  are  referred  to  else- 
where. Surgical  measures  for  treating  the  prolapsed  uterus  are  extremely 
numerous.  They  may  be  divided  into  vaginal  operations  which  seek  to  build  up 
a  support  from  below,  and  abdominal  operations  by  which  the  uterus  is  restored 
to  position  by  some  form  of  artificial  suspension.  Vaginal  operations,  in  general, 
are  less  efficacious  than  those  of  the  abdominal  type. 

The  abdominal  operations  for  prolapse  are,  for  the  most  part,  identical  with 
those  for  retroversion.  It  should  be  remembered,  however,  in  operating  for 
prolapse  that  the  operation  must  not  only  serve  to  keep  the  uterus  forward  in 
anteversion,  but  that  the  suspension  must  take  the  place  of  the  lost  strength 
of  the  pelvic  diaphragm,  and  must,  therefore,  be  capable  of  sustaining  the  weight 
of  the  pelvic  organs  and  resisting  abdominal  pressure.  Some  of  the  operations 
recommended  for  retroversion  are  not  always  to  be  rehed  upon  for  prolapse. 
The  operations  of  the  reduplicating  type  (Wjdie's,  Coffey's,  Baldy's)  have  not 
sufficient  sustaining  power,  and  are  unreliable  if  the  uterus  is  heavy  or  if  the 
prolapse  is  marked. 

The  operations  of  the  Gilliam  type  are  efficacious  in  suspensory  power,  but 


474  GYNECOLOGY 

do  not  control  sufficiently  well  the  position  of  the  uterus,  for  by  these  operations 
the  uterine  body  is  apt  to  be  faced  toward  the  abdominal  wall  and  the  cervix 
tilted  forward  toward  the  pubes. 

The  best  operation  in  our  experience  is  that  of  the  Olshausen  type.  The 
suspensory  effect  of  the  artificial  adhesions  created  by  this  operation  can  be 
very  accurately  regulated.  If  the  uterus  is  large  and  heavy  or  there  is  marked 
prolapse,  a  more  powerful  attachment  is  gained  by  passing  the  ligatures  through 
the  bases  of  the  round  ligaments,  even  including  the  uterine  tissue  itself.  The 
size  and  streng-th  of  the  artificial  adhesions  may  be  governed  by  the  amount  of 
contiguous  peritoneal  surfaces  included  in  the  hgatures,  while  the  amount  of 
reduction  of  the  prolapse  can  be  regulated  by  the  point  of  attachment  on  the 
anterior  abdominal  wall. 

By  attaching  the  uterus  sufficiently  high  on  the  abdominal  wall  the  tendency 
of  the  cervix  to  s^ving  forward  is  usually  overcome,  especially  if  the  operation 
for  cystocele,  described  on  page  608,  is  performed  at  the  same  time.  It  is  occa- 
sionally necessary  to  shorten  the  uterosacral  Hgaments  to  prevent  the  forward 
sag  of  the  cervix. 

In  some  cases  of  prolapse  suspension  of  the  uterus  to  the  abdominal  wall 
is  not  symptomatically  successful.  These  are  the  cases  of  large  permanently 
hypertrophied  uteri,  associated  with  thin,  flabby  abdominal  wall  and  diastasis 
of  the  recti  muscles.  The  weight  of  such  a  uterus  from  its  new  attachment 
causes  symptoms  even  more  troublesome  than  did  the  preceding  prolapse. 
In  this  type  of  case  the  interposition  operation  of  Watkins  and  others  is  applic- 
able. We,  however,  would  prefer  to  remove  the  uterus,  employing  the  technic 
recommended  for  operations  for  procidentia  (see  page  696).  Patients  with  this 
type  of  prolapse  are  usually  multiparous  worn-out  women,  to  whom  the  removal 
of  the  uterus  is  a  blessing. 

The  question  of  operating  on  women  with  prolapse  who  are  hkely  to  have 
more  children  is  one  which  the  surgeon  has  frequently  to  meet.  This  must  be 
decided  chiefly  on  the  ground  of  the  severity  of  the  sjmiptoms.  Where  there  is 
much  disability  or  great  nervous  disturbance  it  is  best  to  advise  operation,  even 
at  the  risk  of  a  later  pregnancy  and  the  possible  chance  of  another  operation 
for  lacerations.  If  the  operation  for  prolapse  is  done  properly  the  patient  can 
be  assured  the  chances  of  dystocia,  or  recurrence  of  the  prolapse  after  childbirth, 
are  exceedingly  small.  She  should,  however,  be  told  that  there  can  be  no 
guarantee  against  new  lacerations  of  the  cervix  or  perineum. 

If  symptoms  are  not  too  severe,  and  there  is  reasonable  expectation  of  an  early 
pregnancy,  the  patient  should  be  treated  palliatively  and  operation  deferred. 

The  question  of  operation  sometimes  arises  where  there  is  considerable  pro- 
lapse, but  no  symptoms.  If  it  is  apparent  that  the  condition  is  hkely  to  get  worse, 
operation  is  advisable.  If  the  prolapse  seems  to  have  reached  its  hmit,  the  deci- 
sion must  be  conservative.  Judgment  as  to  the  future  outcome  of  a  given  case 
is  only  gained  by  experience. 


MALPOSITIONS    OF    THE    UTERUS 


475 


PROCIDENTIA 

Procidentia,  as  we  have  defined  it,  relates  to  an  extreme  degree  of  prolapse, 
and  is  applied  to  the  condition  in  which  the  cervix  extrudes  from  the  vaginal 
introitus.  It  may  seem  somewhat  arbitrary  to  make  a  sharp  distinction  between 
partial  prolapse  and  procidentia,  as  they  are  different  stages  of  the  same  process. 
The  distinction,  however,  is  convenient,  as  there  are  definite  clinical  differences 
between  the  two  conditions. 


Fig.  196. — Procidentia. 
Elongated  cervix  ulcerated.     (Drawn  after  an  illustration  by  Watkins.) 


Procidentia,  though  it  may  occur  at  any  age  from  twenty-five  on,  is  more 
commonly  an  affliction  of  middle  or  later  life.  It  is,  as  a  rule,  very  gradually 
developed,  the  condition  being  accelerated  by  the  physiologic  weakening  of  the 
pelvic  supports  that  occurs  at  and  after  the  menopause.  Rarely  it  may  be 
seen  in  young  women  a  few  months  after  labor. 

The  change  from  prolapse  to  procidentia — i.  e.,  the  protrusion  of  the  cervical 
orifice  beyond  the  vaginal  introitus — sometimes  gives  the  patient  the  impression 


476 


GYNECOLOGY 


that  the  condition  has  developed  suddenly,  especially  if  the  prolapse  has  not 
been  noticed  or  if  the  perineum  has  been  sufficiently  small  to  obstruct  tempo- 
rarily the  onward  progress  of  the  down-coming  cervix.  It  should  be  remem- 
bered, however,  that  the  presence  of  a  procidentia  indicates  a  gradual  and 
usually  slow  progress.  It  is  not  brought  on  suddenly  from  a  normal  condition 
by  falls,  jars,  and  other  forms  of  traumatism. 

The  existence  and  extent  of  procidentia  are  not  necessarily  dependent  on 
the  number  of  labors  through  which  the  patient  has  passed,  but  rather  on  the 
individual  character  of  the  pelvic  supporting  tissues.    It  is  a  noticeable  fact  that 


Fig.  197. — Procidentia.     Typical  Case. 


the  mothers  of  very  large  famihes  often  suffer  very  little  damage  from  their 
repeated  labors,  while  other  women,  with  a  very  limited  number  of  childbirths, 
may  exhibit  extreme  relaxation. 

Congenital  procidentia  is  a  term  somewhat  improperly  applied  to  nulhparous 
women  who  develop  the  condition.  It  is  implied  that  there  exists  a  congenital- 
tissue  deficiency  in  the  pelvic  supports,  but  not  that  the  procidentia  appears 
in  infancy.  It  may  come  to  notice  in  comparatively  young  women,  often  not 
until  the  approach  of  or  even  after  the  menopause.  In  the  congenital  type  the 
descent  represents  chiefly  a  continued  elongation  of  the  cervix.     As  there  have 


MALPOSITIONS    OF    THE    UTERUS  477 

been  no  previous  lacerations,  cystocele,  rectocele,  and  hypertrophy  of  the  cervix 
are  less  marked  than  in  the  ordinary  procidentia  that  results  from  childbirth. 

The  extrusion  of  the  cervix  in  procidentia  is  in  most  cases  primarily  due  to  its 
elongation.  This  lengthening  process  of  the  cervix  occurs  in  nearly  all  cases  of 
marked  prolapse,  and  is  probably  brought  about  by  the  effect  of  abdominal 
pressure  on  the  bladder,  which,  by  its  attachment  to  the  cervix,  gradually  draws 
the  cervix  out  into  an  attenuated  cord.  The  cervix  may  reach  the  length  of  4  or 
5  inches,  and  can  be  felt  by  rolling  the  extruding  mass  between  the  thumb  and 
forefinger.  The  external  end  of  the  cervix  usually  becomes  hypertrophied,  some- 
times to  a  great  extent.  The  lower  extremity  of  the  bladder  averages  from 
I  to  1  inch  from  the  border  of  the  anterior  lip  of  the  cervix  and  represents  a  large 
diverticular  pouch.  Behind  the  cervix  is  another  pouch,  which  is  the  prolapsed 
culdesac  of  Douglas.  Rectocele  may  or  may  not  be  present,  but  usually  is  to 
some  extent.  The  levator  ani  muscles  are  always  widely  separated,  and  usually 
atrophied  as  a  result  of  the  wedge-like  pressure  of  the  extruding  mass. 

The  vaginal  membrane  covering  the  extruded  parts  attains  a  characteristic 
dry,  cornified  surface.  On  the  cervical  lips  and  sometimes  on  other  portions 
of  the  mass  are  often  seen  decubitus  ulcers  with  sharply  defined  edges  and 
granulating  surfaces  covered  with  yellowish  sloughs.  To  one  unaccustomed  to 
the  appearance  of  procidentia  a  severe  case  with  ulcerations  is  an  alarming  sight, 
and  many  times  the  diagnosis  of  malignant  disease  is  made.  It  should  be 
remembered,  however,  that  notwithstanding  the  traumatism  the  cervix  receives, 
procidentia  rarely  results  in  carcinoma. 

As  a  rule,  the  fundus  of  the  uterus  does  not  extrude  from  the  vaginal  outlet, 
the  increase  in  the  length  of  the  procidentia  being  due  to  the  gradual  elongation 
of  the  cervix.  Occasionally  the  entire  body  of  the  uterus  with  its  appendages 
may  be  included  in  the  mass  (Fig.  194). 

An  important  feature  of  the  pathologic  anatomy  of  procidentia  is  the  separa- 
tion 'Of  the  vaginal  wall  from  its  attachments  to  the  rami  of  the  pubes.  Tjiese 
attachments  are  a  very  important  element  in  the  snp'po.rt  of  the  uterus,  and  the 
amount  oi  descensus  of  the  uterus  depends  chiefly  on  the  degree  of  their  separa- 
tion. In  extreme  form's  of  procidentia  the  vagina  is  cojnpletely  detached  from 
the  pubic  rami,  a  point  of  significance  in  the  matter  of  treatment. 

A  special  form  of  procidentia  is  that  which  results  from  an  improperly 
performed  hysterectomy,  by  which  the  vault  of  the  vagina  is  not  adequately 
suspended.  This  may  follow  either  a  supravaginal  or  complete  hysterectomy, 
but  is  more  frequently  seen  after  the  latter.  In  this  form  of  procidentia  the 
vagina  is  turned  inside  out,  the  bladder  coming  down  with  the  anterior  wall. 

The  diagnosis  of  procidentia  is  usually  perfectly  obvious.  It  should  rarely 
be  confused  with  cancer,  but  if  the  ulcerations  are  at  all  suspicious  a  specimen 
should  always  be  removed  and  examined  microscopically.  It  is  of  the  utmost 
importance  to  reduce  the  procidentia  and  make  a  bimanual  examination,  as  the 
condition  may  be  caused  either  by  pregnancy  or  a  pelvic  tumor  or  by  ascites. 


478  GYNECOLOGY 

Symptoms. — As  has  been  stated  before,  the  symptomatology  of  prolapse  of 
the  uterus  is  not  always  proportionate  to  the  amount  of  descensus  of  the  uterus, 
and  this  is  noticeable  in  procidentia,  for  some  women  with  very  marked  falling 
of  the  womb  have  astonishingly  little  disturbance  beyond  the  discomfort  of  the 
prolapsed  mass  between  the  thighs.  Many  women  will  endure  a  procidentia  for 
years  without  complaint. 

Just  why  some  patients  with  moderate  grades  of  prolapse  often  suffer  greater 
sense  of  pressure  and  more  serious  nervous  reaction  than  do  some  with  extreme 
descensus  has  not  been  entirety  explained.  No  doubt  the  personal  -equation  is 
an  important  element,  for  it  is  a  matter  of  common  observation  that 'women  who 
go  for  years  with  a  procidentia  without  impairment  of  their  normal  activities- 
are  of  the  strong  self-reliant  type,  while  those  in  whom  moderate  prolapse  pro- 
duces serious  symptoms  can  usually  be  shown  to  be  naturally  of  unstable  phys- 
ical and  nervous  equilibrium. 

On  the  other  hand,  the  suffering  from  procidentia  may  be  extreme,  and 
patients  are  sometimes  entirely  incapacitated,  even  from  walking.  Nervous 
manifestations  may  be  severe,  even  to  the  point  of  insanity,  especially  in  cases  of 
procidentia  following  hysterectomy.  In  the  latter  class  the  psychic  element  result- 
ing from  disappointment  at  the  failure  of  the  operation  plays  a  significant  part. 

Urinary  symptoms  are  common  owing  to  inability  completely  to  evacuate 
the  bladder.  Constipation  is  also  frequently  present,  especially  if  there  is  a 
rectocele.  Sometimes  neither  the  act  of  urination  nor  -of  defecation  can  be 
accomplished  without  manual  reduction  of  the  prolapsed  parts. 

Bleeding  and  a  foul  -discharge  may  result  from  the  ulceration  of  the  'surface, 
and  are  signs  which  often  lead  to  the  diagnosis  of  cancer. 

The  treatment  of  procidentia  is  either  palliative  or  surgical.  As  procidentia 
often  occurs  in  elderly  or  aged  women  in  whom  a  surgical  operation  might  be 
dangerous,  palliative  treatment  is  not  infrequ-ently  indicated.  This  consists 
chiefly  in  the  use  of  various  form^  of  pessaries  and  uterine  stipports.  Hard- 
rubber  pessaries  are  the  best  to  use  if  they  can  be  fitted  properly.  The  particu- 
lar form  of  pessary  can  only  be  determined  by  trial.  The  -soft-rubber  doughnut 
pessaries  become  foul  very  quickly,  but  sometimes  it  is  necessary  to  use  them. 

Many  cases  of  procidentia  cannot  be  kept  reduced  by  any  of  the  pessaries 
in  common  use.  This  is  particularly  true  ivhen  the  vaginal  walls  roll  out  in 
voluminous  folds,  carrying  the  pessary  with  them;  so  that  there  is  no  oppor- 
tunity for  it  to  engage  behind  the  pubic  arcK.  The  only  support  which  can 
hold  up  such  a  uterus  is  the  cup-pessary,  fitted  with  a  stem  and  harness.  This 
type  is  uncomfortable  and  almost  sure  to  cause  ulceration,  and  should  rarely 
be  employed.  Some  women  are  able  to  keep  fairly  comfortable  by  wearing  a 
very  tight  perineal  bandage  with  a  supporting  pad. 

At  the  present  day  surgical  treatment  is  much  more  successful  than  formerly. 
Most  cases  can  be  completely  cured  by  operative  methods,  while  all  cases  can 
be  assured  of  rehef.     The  results  of  surgery  are  so  satisfactory  that  operation. 


MALPOSITIONS  OF  THE  UTERUS  479 

should  always  be  advised  except  when  there  is  some  strong  contra-indication 
in  the  patient's  general  health. 

There  are  numerous  excellent  operations  for  procidentia.  Every  gjTie- 
cologic  surgeon  of  experience  has  his  individual  technic,  and  it  would  be  impos- 
sible in  this  w^ork  to  include  all  the  various  methods  that  give  good  results. 
Several  of  the  operations  in  common  use  are  described  in  detail  in  the  section 
on  Surgical  Technic.  It  may  be  said,  in  general,  that  the  best  operations  now 
used  can  be  divided  into  two  classes — those  that  emploj^  the  interposition  prin- 
ciple, and  those  that  depend  on  artificial  suspension  from  the  abdomen. 

B}^  "interposition"  is  meant  the  separation  of  the  uterus  from  the  bladder, 
rotating  the  fundus  far  forward,  and  stitching  the  bladder  on  the  posterior 
surface  of  the  uterus.  The  uterus  thus  acts  as  a  support  to  the  bladder,  reducing 
the  cystocele. 

The  operation  is  described  in  detail  on  page  699. 

To  Dr.  Watkins,  of  Chicago,  is  due  the  chief  credit  of  this  operation.  The 
principle  is  extensively  used  in  the  European  clinics  and  it  has  many  adherents 
in  this  country.     Those  who  use  the  operation  report  excellent  results. 

The  principle  of  suspension  is  also  widely  used  in  this  countrj'-,  though  in 
its  use  there  is  a  great  variety  of  technic.  The  author  favors  this  principle, 
and  a  detailed  description  of  the  operation  used  by  him  is  given  on  page  696. 
This  operation  involves,  first,  an  amputation  of  the  elongated  cervix,  plastic 
repair  of  the  cystocele,  and  repair  of  the  relaxed  perineum.  The  second  part 
of  the  operation  consists  in  performing  a  supravaginal  hysterectomy,  attaching 
the  remaining  cervical  stump  to  the  broad  ligaments,  interposing  the  cervical 
stump  under  the  bladder,  and  then  attaching  it  to  the  anterior  abdominal  waU. 

Other  operations  described  in  the  section  on  Technic  are  those  recommended, 
by  Goffe,  Baldy,  Crile,  Mayo,  etc. 

The  operative  methods  thus  far  referred  to  practically  preclude  a  later 
pregnancy,  though  some  cases  of  successful  childbirth  have  been  reported  fol- 
lowing the  interposition  operation. 

Procidentia  may  occur  in  comparative!}^  young  women  who  wish  more 
children.  These  patients  can  be  greatly  relieved  by  the  performance  of  an 
operation  similar  to  that  recommended  for  partial  prolapse,  and  yet  be  left 
in  a  condition  in  which  the  danger  of  serious  dystocia  is  practically  absent.  The 
operation,  as  already  noted,  consists  of  plastic  repair  of  the  cervix,  anterior 
wall,  and  perineum,  together  with  a  suspension  of  the  uterus,  preferably  by  the 
Olshausen  method. 

The  cervix  is  not  so  apt  to  be  elongated  in  younger  women,  but  it  may  be. 
If  it  is  necessary  to  amputate  it,  the  operation  of  Hegar  (described  on  page  599) 
is  the  best  to  emplo}',  as  by  this  method  exact  approximation  can  be  attained 
with  first-intention  healing.  It  is  of  great  importance  to  avoid  the  formation 
of  scar-tissue,  which  may  serve  either  to  prevent  impregnation  or,  if  conception 
does  take  place,  to  interfere  seriously'  with  childbirth. 


480  GYNECOLOGY 

ANTEFLEXION 

The  uterus  is  normally  anteflexed  at  the  junction  of  the  cervix  and  fundus. 
The  term  "anteflexion,"  however,  is  commonly  used  to  denote  an  abnormally 
sharp  angulation.  It  is  difficult  to  state  precisely  the  limit  of  normal  ante- 
flexion, for  what  may  be  normal  in  one  individual  might  be  abnormal  in  another. 
It  is  usually  stated  that  if  the  angle  between  cervix  and  body  is  less  than  90 
degrees  it  is  pathologic.  The  angle  may  be  so  acute  that  the  fundus  and  cervix 
are  nearly  parallel.  The  cervix  is  usually  abnormally  long,  and  may  equal  or 
even  exceed  the  length  of  the  fundus. 

The  uterus  may  acquire  anteflexion  by  the  pressure  of  overlying  tumors, 
by  contracting  adhesions,  or  by  relaxed  supports.  The  first  of  these  causes 
is  not  common.  Contracting  adhesions  may  produce  anteflexion  bj^  forming 
on  the  anterior  wall  and  drawing  the  fundus  forward,  or  they  may  form  on  the 
posterior  wall  and  draw  the  center  of  the  uterus  backward,  while  the  fundus 
is  held  forward  by  its  ligaments.  Adhesions  are  a  rare  cause.  Eelaxation  of  the 
uterine  supports  sometimes  acts  in  such  a  way  as  to  allow  the  uterus  to  sag  back 
in  i-tetrocession,  the  fundus,  however,  being  held  forward  by  the  round  hgaments. 
This  is  quite  common.  In  the  greatest  number  of  cases  anteflexion  is  the 
result  of  a  faulty  development,  and  is  usually  associated  with  other  defects  in 
the  uterus.  The  typical  anteflexed  uterus  is  hypoplastic  and  the  cervix  is  long 
and  conical.  The  uterus,  as  a  whole,  in  most  cases  lies  abnormally  far  back 
in  the  hollow  of  the  sacrum,  in  the  position  already  described  as  that  of  retroces- 
sion. The  cervix  points  either  in  the  direction  of  the  vaginal  axis,  or  forward 
toward  the. anterior  vaginal  wall.  This  form  and  position  of  the  uterus  is  that 
which  is  normally  found  before  puberty.  The  condition  is,  therefore,  one  of 
infantilism. 

Other  evidences  of  hypoplasia  are  also  frequently  found,  as  a  short  anterior 
or  posterio-r  vaginal  wall,  short  uterosacral  ligaments,  infantile  type  of  ovaries, 
etc. 

Besides  the  local  hypoplasia  of  the  pelvic  organs  the  individual  may  exhibit 
evidences  of  infantihsm  in  many  parts  of  her  physical  make-up.  On  the  other 
hand,  the  deficient  development  may  appear  only  in  the  pelvic  organs  of  an 
individual  otherwise  fulh'  matured. 

In  the  severe  cases  of  anteflexion  there  is  usually  to  be  found  at  the  internal 
OS  a  cicatricial  thickening  which  produces  a  certain  amount  of  stenosis  of  the 
canal.  This  occurs  more  often  on  the  posterior  wall,  but  may  be  on  the  anterior, 
or  it  may  involve  the  entire  circumference  as  an  annular  constricting  band. 
The  signiflcance  of  this  process  is  discussed  elsewhere. 

The  small  anteflexed  uterus  feels,  on  examination,  to  be  rather  firm  and 
unyielding,  but  when  the  patient  is  anesthetized  it  is  found  to  be  softer  and  more 
flaccid  and  with  less  erectile  power  than  the  normal  uterus  under  like  conditions. 
This  would  indicate  a  deficiency  in  the  musculature.     This  is  another  evidence 


MALPOSITIONS    OF    THE    UTERUS  481 

of  infantilism,  for  it  is  known  that  in  the  uterus  before  puberty  the  connective 
tissue  predominates  over  the  muscular  tissue,  whereas  in  the  properly  developed 
uterus  the  reverse  is  true. 

Symptoms. — Anteflexion  may  exist  without  symptoms,  but  it  is  usually 
associated  with  either  dysmenorrhea  or  sterility,  or  both.  There  seems  to  be 
no  doubt  that  these  symptoms  are  in  some  way  the  mechanical  result  of  the 
angulation  and  constriction  of  the  uterine  canal,  but  just  how  they  are  pro- 
duced has  not  yet  been  satisfactorily  explained.  The  relationship  of  ante- 
flexion to  dysmenorrhea  and  sterility  is  dwelt  on  in  the  sections  on  those  sub- 
jects. 

The  retrocession  of  the  uterus  commonly  met  with  in  anteflexion  often 
produces  symptoms  identical  with  those  from  retroversion,  and  for  the  same 
reason.  In  fact,  the  cervix,  both  in  retroversion  and  retroflexion,  is  practically 
in  the  same  position.  Hence  it  is  that  patients  with  anteflexion  often  complain 
of  backache  and  pain  in  the  sides  of  the  pelvis,  the  latter  symptom  being  due  to 
stasis  of  the  vems  in  the  broad  ligament. 

It  has  been  our  experience  that  patients  with  anteflexion  are  especially  prone 
to  chronic  appendicitis,  but  no  adequate  explanation  of  this  can  be  given. 

Women  in  whom  anteflexion  produces  dysmenorrhea  nearly  always  have 
an  unstable  nervous  equilibrium.    (See  Dysmenorrhea  and  section  on  Neurology.) 

The  diagnosis  of  anteflexion  is  readily  made  by  passing  the  examining  finger 
along  the  anterior  wall  of  the  cervix  and  pressing  deeply  into  the  anterior  vault 
of  the  vagina,  when  the  angle  between  cervix  and  body  of  the  uterus  can  always 
be  felt.  Mistakes  are,  however,  frequently  made  on  account  of  the  retroces- 
sion of  the  uterus  and  the  forward  direction  of  the  cervix,  which  on  hasty  ex- 
amination give  the  impression  of  a  retroversion.  A  myoma  centrally  placed 
on  the  anterior  wall  of  the  fundus  may  simulate  closely  an  acute  anteflexion. 

The  treatment  of  anteflexion  of  the  uterus  is  mentioned  in  detail  in  Part  III. 
It  comprises  four  methods:  the  use  of  stem-pessaries,  instrumental  dilatation, 
plastic  operations  on  the  cervix,  and  suspension  of  the  uterus  from  the  anterior 
abdominal  wall.  By  the  orthopedic  or  pessary  method  a  straight  or  shghtly 
bent  canahzed  stem,  usually  made  of  hard  rubber,  is  inserted  in  the  uterine  canal, 
where  it  is  kept  for  six  weeks  or  two  months.  Dysmenorrhea  and  sterility  are 
sometimes  entirely  cured  by  this  measure,  but  it  is  to  be  remembered  that  it 
may  cause  infection  of  the  tubes.  The  use  of  stem-pessaries  sometimes  perma- 
nently reduces  the  anteflexion,  but  frequently  the  uterus  returns  to  its  former 
position.  The  recurrence  of  the  anteflexion  is  not  always  accompanied  by  a 
return  of  the  symptoms. 

Dilatation  of  the  cervical  canal  should  be  done  under  an  anesthetic,  and  is 
best  performed  with  Hank's  graduated  dilators. 

If  a  cicatricial  band  is  present  at  the  internal  os  the  dilatation  may  be  diffi- 
cult.    It  is  sometimes  necessary  to  incise  this  obstruction  with  a  bistoury. 
Simple  dilatation  is  successful  in  a  limited  number  of  cases. 
Si 


482  GYNECOLOGY 

'  Plastic  operations  on  the  cervix  are  numerous,  but,  though  occasionally- 
successful,  are  rather  unsatisfactory  in  their  results.  The  operations  most  used 
are:  the  removal  of  a  transverse  wedge  from  the  posterior  wall  of  the  cervix, 
the  posterior  discission,  and  the  bilateral  artificial  laceration.  These  operations 
are  described  in  the  section  on  Technic. 

Suspension. — It  has  been  stated  above  that  the  musculature  of  the  typical 
anteflexed  uterus  is  lax  and  flaccid.  The  characteristic  sagging  back  in  the  posi- 
tion of  retrocession  is,  in  reality,  a  condition  of  relaxation,  differing  only  from 
congenital  or  developmental  retroflexion  in  that  the  fundus  points  forward  in 
relation  to  the  cervix  instead  of  backward.  There  may  even  be  a  limited  amount 
of  descensus.  When  the  abdomen  is  opened  the  anteflexion  may  be  com- 
pletely reduced  by  drawing  the  fundus  upward  toward  the  wound  in  the  ab- 
dominal wall.  By  suspending  the  uterus  the  angulation  can  be  permanently 
reduced.  This  is  best  accomphshed  either  by  the  Gilliam  type  of  operation  or 
by  the  Olshausen  method,  preferably  the  latter.  In  other  words,  anteflexion 
may  be  treated  exactly  as  congenital  retroflexion,  and  this  is  reasonable  because 
the  two  conditions,  from  a  pathologic  standpoint,  are  nearly  the  same. 

The  results  of  the  suspension  operation  for  anteflexion  are  not  always  suc- 
cessful either  for  dysmenorrhea  or  for  sterility,  but  in  the  experience  of  the 
writer  they  are  considerably  more  satisfactory  than  those  secured  by  the  other 
methods  mentioned  above. 

In  all  cases,  of  anteflexion  the  presence  of  a  cicatricial  band  at  the  internal 
OS  makes  the  prognosis  worse  as  regards  curing  the  symptoms.  If  the  suspen- 
sion operation  is  employed  it  should  always  be  preceded  by  a  thorough  dilatation 
of  the  cervix. 

INVERSION   OF  THE   UTERUS 

Inversion  of  the  uterus  is  due  primarily  to  a  relaxation  of  the  uterine  wall 
and  most  frequently  occurs  as  a  comphcation  of  childbirth.  It  may  also  result 
gradually  from  the  traction  of  a  submucous  or  pedunculated  fibroid  or  from 
cancer,  so-called  onkogenetic  inversion.  That  the  condition  even  after  chfld- 
birth  is  a  rare  one  is  shown  by  Jones'  collected  figures,  which  show  an  average 
of  1  case  in  128,767  labors. 

Inversion  of  the  uterus  is  either  acute  or  chronic,  those  cases  which  last  a 
month  or  less  being  called  acute,  those  seen  at  a  period  longer  than  this  being 
regarded  as  chronic.  Inversions  from  gynecologic  causes — i.  e.,  the  traction  of 
tumors — are  always  of  the  chronic  type. 

The  inversion  is  called  "incomplete"  when  the  fundus  does  not  pass  the  cervix, 
and  "complete"  when  it  extends  beyond  this  point.  In  very  rare  instances  the 
inversion  includes  the  cervix,  so  that  the  entire  organ  is  inside  out.  Usually, 
however,  the  cervix  remains  as  a  sort  of  coflar  about  the  inverted  fundus. 

In  all  chronic  cases  the  cervix  is  firmly  contracted,  while  in  the  acute  cases 
following  labor  it  becomes  contracted  very  quickly,  from  a  few  minutes  to  a 


MALPOSITIONS    OF    THE    UTERUS 


483 


few  hours  (W.  C.  Jones).  In  acute  cases  the  inverted  fundus  is  large,  but  in 
the  chronic  form  it  may  become  markedly  involuted  (Hoover).  Some  cases  of 
gangrene  have  been  reported  where  the  circulation  has  been  cut  off.  If  there 
is  an  associated  prolapse  or  a  pedunculated  myoma  the  mass  may  extrude  from 
the  vulva. 

The  symptoms  of  acute  inversion  are  shock  and  hemorrhage,  cases  of  this 
kind  being  entirely  within  the  sphere  of  obstetrics.  The  symptoms  of  chronic 
inversion  are  similar  to  those  of  prolapse. 

The  diagnosis  in  acute  cases  is  usually  unmistakable,  but  in  the  chronic 
variety  it  maj^  offer  considerable  difficulty.  The  condition  with  which  inversion 
is  most  apt  to  be  confounded  is  that  of  a  pedunculated  fibroid.     When  the  fibroid 


Fig.  198. — Myomatous  Polyp. 

Distinguished  from  inversion  by  a  deepening  of 

the  uterine  canal. 


lV\vio\-n.cx 


Fig.  199. — Myoma    Causing    Inversion    by 

Traction. 

Distinguished  from  simple  polyp  by  shortening 

the  uterine  canal. 


and  inversion  occur  simultaneously  the  diagnosis  is  still  more  puzzling.  W.  C. 
Jones  has  offered  an  excellent  means  of  differentiation  in  pointing  out  that  the 
key  to  the  situation  is  the  length  of  the  uterine  canal,  a  fibroid  always  producing 
elongation;  inversion  always  shortening  it.  The  accompanying  diagrams  illus- 
trating this  point  are  adapted  from  Jones'  article. 

If  the  patient's  abdomen  is  not  too  thick,  the  depression  from  the  abdominal 
side  caused  by  the  inversion  can  be  felt  by  bimanual  examination. 

The  treatment  of  acute  inversion  is  immediate  manual  reposition.  If  this 
is  difficult,  it  is  better,  according  to  Kiistner,  to  resort  at  once  to  the  conservative 
method  of  operation  described  in  Part  III. 

Surgical  treatment  of  chronic  inversion  is  either  radical  or  conservative,  the 
choice  of  which  course  is  determined  as  in  other  uterine  conditions.'    Thus,  if 


484  GYNECOLOGY 

the  uterus  be  studded  with  fibroids,  or  if  there  is  suggestion  of  malignancy,  or 
if  the  patient  is  past  the  menopause,  extirpation  of  the  uterus  is  indicated. 
This  can  be  done  by  the  abdominal  or  the  vaginal  route,  the  former  being  recom- 
mended because  of  the  better  opportunity  of  preventing  a  future  prolapse  of 
the  vagina. 

Of  the  conservative  operations,  that  devised  by  Kiistner  and  termed  "colpo- 
hysterotomy"  is  the  classical  method,  though  it  has  been  modified  to  some 
extent  by  others.  Two  forms  of  operation  are  described  in  the  section  on 
Operative  Surgery. 

Vaginal  amputation  of  the  extruded  fundus  is  sometimes  done,  but  is  an 
operation  not  to  be  highly  recommended.  The  same  may  be  said  of  reposition 
of  the  inverted  uterus  by  the  abdominal  route. 


Injuries  due  to  Childbirth 
laceration  of  cervix 

Lacerations  of  the  cervix  usually  result  from  childbirth,  especially  when 
there  has  been  instrumental  delivery.  They  are  also  caused  by  dilatation 
operations  and  instrumental  abortions. 

Tears  of  the  cervix,  as  a  rule,  occur  on  one  or  both  sides.  Occasionally 
the  posterior  and,  more  rarely,  the  anterior  lips  are  torn.  If  the  laceration 
takes  place  in  more  than  two  places  it  is  called  stellate. 

The  surface  of  a  cervical  tear  may  heal  over  completely,  leaving  only  a  smooth 
cleft  without  further  change  in  the  cervix.  Usually,  however,  lacerations  pro- 
duce certain  pathologic  conditions,  the  most  important  of  which  are  eversion 
of  the  mucous  membrane  (ectropion) ,  hypertrophy  of  the  lips,  erosion,  and  cyst 
formation  of  the  Nabothian  glands. 

Eversion  or  ectropion  results  from  a  pouting  of  the  cervical  lips  after  lacera- 
tion, by  which  the  mucous  membrane  is  allowed  to  roll  outward  toward  the 
vagina.  This  condition  of  the  mucosa  is  greatly  aggravated  by  the  various 
chronic  inflammatory  changes  in  the  cervical  tissues  that  are  apt  to  ensue  after 
laceration. 

Hypertrophy  of  the  cervix  following  laceration  relates  to  an  enlargement 
of  the  cervical  lips,  which  sometimes  is  very  great.  This  increase  in  size  is  due 
partly  to  an  actual  hyperplasia  of  the  cervical  connective-tissue  stroma,  partly 
to  a  chronic  inflammatory  infiltration,  and  partly  to  a  general  edema  of  the 
tissues.  A  further  important  factor  in  the  enlargement  of  the  cervix  is  depend- 
ent on  the  change  in  the  endocervical  glands.  These  glands,  it  will  be  remem- 
bered, are  of  a  complicated  racemose  type,  with  small  single  ducts  opening  into 
the  cervical  canal.  The  ducts  easily  become  obstructed  with  resultant  cyst 
formation  of  the  main  portion  of  the  gland.  If  a  number  of  the  glands  become 
cystic  the  cervix  may  be  enormously  enlarged.  The  contents  of  the  cysts  con- 
sist primarily  of  true  mucus  from  the  secreting  lining  cells  of  the  glands,  but  there 
is  apt  to  be  a  mixed  infection  which  adds  products  of  inflammation  and  detritus 
to  the  mucous  material.  The  mucous  membrane  of  an  everted  cervix  is  practically 
'always  infected,  and  frequently  shows  microscopically  a  necrosis  and  desquama- 
tion of  the  superficial  epithelium.  If  this  condition  becomes  sufficiently  exten- 
sive to  be  recognized  by  inspection  it  is  termed  "erosion."  Erosion  and  ulcera- 
tion of  the  cervix,  as  a  result  of  a  laceration  and  its  attendant  cervicitis,  is  not  as 
common  as  is  supposed.  The  everted  mucous  membrane  has  a  deep  red  appear- 
ance, which,  to  the  inexperienced  eye,  gives  the  impression  of  a  loss  of  surface 

485 


486  GYNECOLOGY 

tissue.  The  diagnosis  of  "ulceration  of  the  cervix"  is,  therefore,  verj^  often 
erroneousl}^  made.  True  ulceration  where  observed  must  always  be  regarded 
with  concern,  as  it  is  hkety  to  indicate  some  form  of  disease  more  serious  than 
simple  cervicitis.  Its  appearance  demands  a  removal  of  tissue  for  microscopic 
examination. 

The  spontaneous  heaUng  of  cervical  tears  is  often  attended  with  dense 
scar-formation  most  marked  in  the  angles  of  the  lacerations.  This  scar- 
formation  may  extend  out  on  the  lateral  walls  of  the  vagina  or  upward  into  the 
parametrium.  The  contraction  of  the  scar-tissue  may  immobihze  the  uterus 
to  some  extent,  or  cause  version  of  the  body  to  one  side  or  backward. 

Symptoms.^ — Lacerations  of  the  cervix  do  not  cause  definite  local  pain,  as 
the  cervix  is  a  peculiarly  insensitive  organ.  The  hypertrophy  of  the  hps  in- 
creases the  weight  of  the  uterus,  and  as  there  is  usuall}^  some  prolapse  asso- 
ciated with  severe  lacerations,  the  sense  of  weight  and  pelvic  pressure  is  often 
present.  Backache  is  a  somewhat  inconstant  symptom.  If  the  uterus  is 
immobihzed  by  scar-tissue  in  the  parametrium  there  is  increased  pelvic 
discomfort.  Ectropion  always  produces  leukorrhea  and  sometimes  irregular 
bleeding. 

Numerous  so-called  "reflex"  disturbances  from  cervical  tears  have  been 
described,  such  as  headaches,  pains  in  the  spine,  and  various  hysteric  neuroses. 
These  are  undoubtedly  secondary  nervous  manifestations  of  depleted  health 
caused  by  the  damage  to  the  pelvic  organs  in  which  the  lacerated  cervix  is  only 
one  factor. 

Laceration  of  the  cervix  sometimes  causes  sterihty,  probably  as  a  result  of 
the  chemically  changed  secretions  from  the  everted  and  inflamed  mucous 
membrane  which  may  be  inimic  to  the  life  of  the  spermatozoa. 

Women  with  deep  tears  extending  to  the  internal  os  are  very  apt  to  have 
multiple  miscarriages,  probably  due  to  interruption  of  the  normal  function  of 
the  uterine  musculature. 

The  diagnosis  of  lacerated  cervix  is  usually  obvious  both  to  touch  and 
sight.  The  erosion  and  eversion  of  the  mucous  membrane  may  simulate  the 
ulcerations  of  tuberculosis  and  sj^philis,  but  these  latter  are  very  rare. 

It  is  of  the  greatest  importance  to  distinguish  between  severe  laceration  and 
cancer  of  the  cer%dx.  It  is  sometimes  very  difficult  to  make  a  diagnosis  without 
the  removal  of  a  section  for  microscopic  examination.  To  the  touch  the  hard 
hj^pertrophied  lips  of  cervicitis,  made  irregular  and  nodular  by  the  Nabothian 
retention  cysts,  may  be  almost  indistinguishable  from  cancer.  Bleeding  from 
contact  of  the  examining  finger  which  is  so  characteristic  in  cancer  is  sometimes 
met  with  in  cases  of  laceration  with  erosion.  On  inspection  the  Nabothian 
cysts  can  usually  be  readily  seen.  The  presence  of  these  cysts,  as  a  rule,  is 
evidence  against  cancer,  but  this  is  by  no  means  always  the  case. 

It  should  be  remembered  that  cancer  usually  originates  in  one  of  these  lacer- 
ated everted  cervices,  so  that  on  the  least  suspicion  a  specimen  must  be  removed 


INJTJRIES    DUE    TO    CHILDBIRTH  487 

for  microscopic  examination.  In  an  early  cancer  of  the  cervix  the  point  of  origin 
is  not  always  distinguishable.  In  a  doubtful  case,  therefore,  it  is  best  to  remove 
several  pieces. 

Parametrial  cicatrices  sometimes  obscure  the  diagnosis,  for  it  immobilizes 
the  uterus  and  gives  to  the  examining  finger  a  sense  of  indefinite  resistance  in 
the  adnexa  closely  resembling  a  chronic  salpingitis  with  adhesions. 

Treatment  of  Lacerated  Cervix. — Nearly  every  woman  who  bears  a  child 
has  some  laceration  of  the  cervix.  Only  those  require  treatment  that  give 
definite  symptoms,  or  that  by  their  appearance  threaten  the  development  of  a 
cancer.  Unless  the  tears  are  small,  it  is  advisable  always  to  repair  the  cervix 
as  a  routine  during  plastic  operations  of  the  vagina,  and  to  examine  micro- 
scopically the  tissue  removed. 

Eroded  and  inflamed  cervices  may  be  temporarily  improved  by  local  apphca- 
tions  such  as  iodin,  ichthyol,  and  glycerin  tampons,  etc.,  but  they  cannot  in  this 
way  be  permanently  cured. 

Surgical  treatment  is  based  usually  on  the  operation  devised  by  Emmet 
many  years  ago  and  never  improved  upon.  This  consists  in  denuding  the  edges 
of  the  clefts  caused  by  the  laceration,  and  sewing  the  denuded  surfaces  together 
(see  page  593).  If  there  is  great  hypertrophy  of  the  hps  or  extensive  scar- 
tissue  formation  it  may  be  necessary  to  resort  to  other  measures,  as  the  removal 
of  transverse  wedges  from  the  Hps  (see  page  598)  or  to  amputation  of  the  entire 
cervix. 

Unless  the  cervix  is  elongated,  as  in  prolapse  and  procidentia  cases,  it  is 
best  to  perform  a  tracheloplasty  rather  than  amputation  if  there  is  hkelihood  of 
later  child-bearing. 

If  amputation  of  the  cervix  is  necessary,  Hegar's  method  gives  the  best 
results  (see  page  599),  as  it  secures  a  more  accurate  approximation  of  the  wound 
edges  than  does  any  other  form  of  operation. 

CYSTOCELEi 

Cystocele  is  a  descent  of  the  bladder  toward  the  introitus  caused  by  relaxation 
of  the  anterior  vaginal  wall.  In  the  great  majority  of  cases  cystocele  is  one  of  the 
results  of  child-bearing,  though  it  may  occur  in  nulliparous  and  even  in  virgin 
women.  When  not  the  result  of  the  injuries  of  childbirth  it  is  due  to  congenital 
tissue  weakness. 

Cystocele  is  nearly  always  associated  -with  a  greater  or  less  degree  of  prolapse. 
In  general,  the  two  conditions  are  roughly  proportionate  to  each  other.  This 
is  due  to  the  intimate  attachment  which  the  bladder  has  to  the  anterior  wall  of 
the  cervix  uteri,  so  that  neither  organ  can  prolapse  without  a  tendency  to  drag 
the  other  with  it.  Cystocele,  especially  of  the  congenital  type,  is  occasionally 
seen  with  little  or  no  prolapse  of  the  uterus,  but  this  is  uncommon,  and  may  be 

^  For  mechanism,  see  that  of  Prolapse. 


488  GYNECOLOGY 

regarded  as  a  true  hernia  of  the  bladder.  We  do  not,  however,  see  prolapse  of 
the  uterus  without  some  descent  of  the  bladder.  This  is  a  fact  of  great  practical 
importance  in  the  matter  of  treatment,  both  of  cystocele  and  prolapse  of  the 
uterus. 

Cystocele  usually  begins  in  the  upper  anterior  part  of  the  vagina  near  the 
attachment  of  the  bladder  and  cervical  wall.  Where  the  vaginal  wall  has  once 
lost  its  integrity  the  cystocele  is  gradually  increased  by  abdominal  pressure,  and 
in  time  appears  at  the  introitus.  The  exertion  of  abdominal  pressure  by  strain- 
ing or  standing  causes  the  anterior  wall,  with  the  bladder  behind  it,  to  protrude 
into  the  world.  The  constant  application  of  the  force  of  abdominal  pressure 
acts  as  a  drag  on  the  cervix  of  the  uterus,  which  becomes  lengthened  and  attenu- 
ated, until  it  may  reach  the  stage  of  procidentia.  The  force  of  abdominal  pres- 
sure serves  more  and  more  to  drag  the  vagina  away  from  its  attachments  to  the 
rami  of  the  pubes.  As  this  attachment  is  one  of  the  most  important  supports 
of  the  uterus,  the  uterus  itself  prolapses  increasingly. 

The  descent  of  the  bladder  may  include  the  urethra,  and  when  this  takes 
place  the  condition  is  termed  "urethrocele."  Urethrocele  is  usually  only  an 
incidental  part  of  the  process  of  cystocele,  but  it  may  occur  alone. 

If  the  cystocele  extrudes  constantly  from  the  vagina  the  surface  epithelium 
becomes  dry  and  cornified,  and  if  there  is  also  procidentia  it  may  become  ulcer- 
ated. 

The  symptoms  of  cystocele  are  closely  associated  with  those  of  prolapse  of 
the  uterus,  the  chief  one  being  that  of  general  bearing-down  or  pelvic  pressure 
with  tendency  to  fatigue.  This  might  more  properly  be  spoken  of  as  an  asso- 
ciated symptom,  being  due  principally  to  the  prolapse  of  the  uterus.  If  the 
cystocele  is  advanced  the  patient  is  conscious  of  its  protrusion,  often  regarding 
it  as  the  womb.  This  annoyance  may  have  a  deleterious  influence  on  the 
nervous  system  if  the  patient's  mind  becomes  riveted  on  the  local  condition. 
The  involvement  of  the  neck  of  the  bladder  causes  symptoms  of  urinary  irri- 
tability and  frequency,  while  the  sacculated  condition  of  the  bladder  walls 
prevents  complete  voiding,  and  thus  produces  stagnation  and  chemical  changes 
in  the  urine.  Relaxation  of  the  urethra  and  neck  of  the  bladder  may  cause 
partial  incontinence,  especially  in  old  people.  Incomplete  voiding  of  the  urine 
sometimes  encourages  a  cystitis,  though  it  is  surprisingly  uncommon. 

The  diagnosis  of  advanced  cystocele  is  entirely  obvious.  The  milder 
forms  are  diagnosed  by  feeling  the  anterior  wall  near  the  cervical  reflexion,  and 
requesting  the  patient  to  bear  down  as  in  the  act  of  defecation.  There  is  a 
normal  amount  of  bulging  of  the  anterior  wall,  just  as  there  is  a  normal  amount 
of  descent  of  the  uterus,  and  this  must  be  learned  by  experience.  Under  ether 
the  amount  of  cystocele  present  is  demonstrated  by  grasping  the  anterior 
vaginal  wall  with  two  pairs  of  thumb  forceps  and  drawing  it  forward  toward 
the  opening.  The  difference  between  the  normal  and  pathologic  amount  of 
slack  is  easily  learned. 


INJURIES    DUE    TO    CHILDBIRTH  489 

The  diagnosis  of  urethrocele  is  determined  by  passing  a  sound  into  the 
urethra.  It  should  be  remembered  that  there  is  apt  to  be  a  considerable  hyper- 
trophy of  the  anterior  vaginal  wall  at  the  level  of  the  urethra.  This  hyper- 
trophied  protrusion  is  sometimes  taken  for  a  cystocele  or  for  urethrocele. 

Treatment. — The  following  remarks  on  the  treatment  of  cystocele  relate  to 
the  method  of  treating  genital  prolapse  by  suspension,  and  are  not  entirely 
applicable  to  the  interposition  method,  which  involves  a  different  mechanical 
principle.     A  description  of  the  latter  technic  is  given  on  page  608. 

In  treating  cystocele,  one  should  always  remember  its  close  relationship  to 
prolapse  of  the  uterus,  and  regard  the  two  conditions  as  phases  of  the  same 
process.  Failure  to  appreciate  this  fact  led  some  of  the  older  operators  to 
regard  cystocele  as  incurable.  This  is  because  the  simple  performance  of  a 
plastic  operation  on  the  anterior  wall  of  the  vagina,  without  permanently  cor- 
recting the  associated  prolapse  of  the  uterus,  will  almost  certainly  be  followed  by 
a  recurrence  of  the  cystocele. 

On  the  other  hand,  however,  the  reduction  of  the  prolapse  of  the  uterus  will, 
at  the  same  time,  reduce  milder  grades  of  cystocele  without  plastic  operation 
on  the  cystocele. 

In  treating  cystocele,  therefore,  it  is  a  fundamental  principle  that  the  most 
essential  part  of  the  operation  is  the  elevation  of  the  cervix,  for  it  is  to  its  cer- 
vical attachment  that  the  bladder  chiefly  owes  its  position  in  the  pelvis.  The 
elevated  cervix  does  not  take  up  all  the  slack  of  the  relaxed  anterior  wall,  and 
this  must  usually  be  corrected  by  a  plastic  operation.  If  the  operation  is  done 
in  this  way  the  reduction  of  the  cystocele  will  remain  permanent. 

Plastic  operations  for  folding  in  the  redundant  anterior  wall  are  numerous. 
A  useful  operation  for  this  purpose  is  described  on  page  608.  This  opera- 
tion, to  be  successful,  must  in  most  cases  be  supplemented  by  some  form  of  sus- 
pension which  will  elevate  the  cervical  attachment  of  the  bladder.  This  is 
accomplished  by  the  methods  described  under  Prolapse  and  Procidentia  of  the 
Uterus. 

A  special  point  to  be  noted  in  the  operation  described  for  cystocele  is  the 
method  of  treating  the  upper  portion  of  the  cystocele  near  the  cervical  reflexion. 
The  denudation  is  carried  out  more  widely  than  at  the  lower  portion,  so  that 
when  the  vaginal  flaps  are  approximated  a  firm  bridge  is  made  across  the  front 
of  the  cervix,  carrjdng  it  backward  toward  the  sacrum.  This  serves  to  correct 
the  tendency  of  the  cervix  in  partial  prolapse  to  swing  toward  the  pubes. 

The  treatment  of  cystocele  by  the  interposition  method  involves  a  separation 
of  the  bladder  from  the  uterus,  and  then  transposition  of  the  bladder  to  the 
posterior  surface  of  the  uterus.  In  this  way  the  uterus  is  brought  under  the 
bladder  and  supports  it  from  below. 


490  GYNECOLOGY 

LACERATED   PERINEUM 

In  order  to  understand  the  mechanism  of  perineal  lacerations  it  is  important 
to  have  a  clear  idea  of  the  essential  points  in  the  anatomy  and  function  of  the 
perineal  muscles.  Unfortunately,  the  subject  is  not  an  easy  one,  for  the  parts 
are  very  difficult  of  dissection  and  the  descriptions  of  them  are,  for  the  most  part, 
vague  and  misleading. 

The  most  practical  demonstration  of  the  functional  anatomy  of  the  pelvic 
diaphragm  which  we  have  seen  is  that  by  Studdiford,  pubHshed  in  Johnson's 
Surgical  Therapeutics.  His  statement  is  so  clearly  expressed  that  we  caimot 
do  better  than  to  quote  it  verbatim : 

"The  levator  ani  muscle,  together  with  the  strong  fascia  covering  its  internal 
and  external  surfaces,  is  conceded  to  be  the  essential  part  of  the  pelvic  diaphragm, 
but  there  is  no  uniformity  of  opinion  as  to  the  relative  value  of  the  two  elements, 
the  mechanism  of  their  action  in  giving  support,  and  how  they  are  affected  by 
injury.  The  levator  ani  is  a  paired  muscle  which  has  its  origin  from  the  tendin- 
ous arch  which  extends  from  the  lower  margin  of  the  pubes  to  the  spine  of  the 
ischiimi,  from  the  inner  surface  of  the  superior  ramus  of  the  pubes,  and  from  the 
pubes  parallel  to  the  symphysis.  The  fibers  coming  from  the  pubes  form  a  dis- 
tinct muscular  band,  the  pubococcygeus  muscle,  and  are  the  most  important  part 
of  the  levator.  The  fibers  from  the  tendinous  arch,  the  ileococcygeal  muscle, 
are  slender  fascicuh  separated  by  small  interspaces.  The  majority  of  the  fibers 
from  the  tendinous  arch  are  inserted  into  the  lateral  margins  of  the  coccyx, 
some  are  joined  with  the  muscles  from  the  opposite  side,  and  others  are  inserted 
into  the  anococcygeal  hgament.  The  fibers  of  the  pubococcygeus  arising  from 
the  pubes  pass  directly  backward,  some  of  the  fibers  uniting  with  the  fibers  of 
the  external  sphincter.  Others  pass  directly  to  the  anococcygeal  hgament, 
while  still  others  join  with  the  fibers  from  the  opposite  side  posterior  to  the 
rectum,  some  of  the  fibers  minghng  with  the  longitudinal  fibers  of  the  rectum. 
The  muscle  is  in  close  relation  with  the  side  walls  of  the  lower  end  of  the  vagina, 
its  fibers  mingling  with  the  longitudinal  fibers  of  the  vaginal  wall.  The  relation 
of  the  muscle  to  the  external  sphincter  is  of  the  utmost  importance  and  is  so 
intimate  that  separation  by  dissection  is  impossible.  Functionally  the  two  mus- 
cles must  be  considered  together  as  forming  a  strong  muscular  band  extending 
from  the  pubis  to  the  coccyx,  controlling  and  embracing  the  lower  end  of  the 
rectum  and  attached  to  the  side  walls  of  the  vagina.  It  is  usual  to  describe  the 
levator  ani  as  a  sling  or  horseshoe-shaped  muscle.  It  would  give  a  more  correct 
idea  of  the  structure  were  it  described  as  V  shaped,  the  angle  of  the  V  being 
much  wider  posteriorly  where  the  muscles  are  attached  to  the  ischial  spines 
and  narrowing  as  the  anterior  fibers  (pubococcygeus)  attached  to  the  pubic 
bone  are  approached.  The  sides  of  the  V  have  a  slight  convexity  toward  the 
median  line,  the  apex  of  the  V  being  the  attachment  to  the  coccjtc.  The  open 
part  of  the  V  between  the  anterior  portion  of  the  pubococcygeus  muscles  is 


INJURIES    DUE    TO    CHILDBIRTH  491 

protected  by  the  urogenital  trigone  made  up  of  two  strong  layers  of  fascia,  in- 
closing between  them  the  deep  transversus  perinei  muscles  together  with  some 
involuntary  muscle-fibers.  The  urogenital  trigone  is  attached  to  the  inner 
margins  of  the  inferior  rami  of  the  pubes  anterior  to  the  tuberosities  of  the  ischii, 
its  sharp  posterior  border  marking  the  anterior  boundary  of  the  ischiorectal 
fossae.  It  is  perforated  by  the  vagina  and  urethra  and  fuses  with  the  fascia 
covering  these  organs.  The  posterior  surface  of  the  trigone  is  in  relation  with 
the  fascia  covering  both  surfaces  of  the  levator  ani  and  gives  support  to  the 
fibers  of  the  pubococcygeus.  The  deep  transversus  perinei,  rising  from  the 
inner  surface  of  the  tuberosity  of  the  ischium  between  the  layers  of  fascia  and 
forming  part  of  the  posterior  half  of  the  urogenital  trigone,  is  attached  along 
with  the  anterior  fibers  of  the  external  sphincter  to  the  so-called  central  tendon 
of  the  perineum.  It  is  this  part  of  the  perineum  that  I  beheve  has  been  im- 
properly described. 

'Tn  an  article  of  mine  in  1909  the  importance  of  the  involuntary  muscle-fibers 
contained  in  the  pelvic  floor  was  emphasized.  The  study  of  these  fibers  was 
based  not  only  on  gross  dissection,  but  on  frozen  sections  and  microscopic  ex- 
amination of  the  tissues  from  the  cadaver  and  microscopic  examination  of  tissue 
removed  from  the  Hving  subjects  during  operative  procedure.  These  observa- 
tions have  been  confirmed  by  study  of  dissections  since  that  time.  These  in- 
vestigations showed  that  the  tissue  lying  between  the  halves  of  the  levator  ani 
and  at  the  points  of  attachment  of  the  anterior  end  of  the  external  sphincter 
and  to  the  deep  transversus  perinei  muscles  in  the  perineal  body  was  made  up 
largely  of  involuntary  muscle-fibers.  These  fibers  running  in  both  a  transverse 
and  longitudinal  direction  are  in  close  relation  to  all  the  muscles.  So  far  as  I 
have  been  able  to  determine,  no  fibers  from  the  two  halves  of  the  levator  ani 
muscle  pass  between  the  vagina  and  rectum.  These  involuntary  muscle-fibers 
we  consider  important  in  the  mechanism  of  the  pelvic  floor,  their  contraction 
tending  to  draw  the  two  halves  of  the  levator  ani  and  the  deep  transversus  peri- 
nei muscles  toward  the  median  Hne,  thus  placing  these  muscles  in  the  most  advan- 
tageous position  for  action,  and  by  drawing  the  anterior  end  of  the  sphincter 
forward  aid  the  supporting  power  of  the  levator.  These  fibers  undoubtedly 
increase  in  size  and  strength  during  the  pregnancy,  and  account  for  the  increased 
projection  and  thickening  of  the  pelvic  floor  at  that  time.  They  also  permit 
the  dilatation  of  the  pelvic  floor  at  the  time  of  labor  and  undergo  involuntary 
changes  after  labor. 

"The  force  of  the  contractions  of  the  levator  ani  are  directed  by  the  course 
of  its  fibers.  In  the  upright  position  the  fibers  of  the  pubococcygeus  run  almost 
horizontal  from  the  pubes  to  a  line  drawn  between  the  tuberosities  of  the  ischii 
which  marks  the  posterior  border  of  the  urogenital  trigone,  to  the  posterior  sur- . 
face  of  which  the  fascia  covering  the  muscle  is  attached.  Posterior  to  this  line 
the  fibers  interminghng  with  the  fibers  of  the  external  sphincter  pass  upward  and 
backward  to  the  coccyx.    So  that  when  contraction  of  the  muscles  takes  place 


492 


GYNECOLOGY 


the  involuntary  fibers  approximate  the  two  halves  of  the  muscles  toward  the 
median  line,  the  urogenital  trigone  is  pulled  upward  and  forward,  closing  the 
vaginal  slit.  The  exaggerated  action  of  these  involuntary  fibers  can  be  seen 
in  cases  of  vaginismus.  The  lower  end  of  the  rectum  is  also  drawn  upward  and 
forward,  and  the  portion  of  the  muscles  posterior  to  the  ischial  tuberosities  is 


Fig.  200. — Semidiageam  Showing  the  Relatioxship  of  the  Perineal  MrscLES. 

On  the  left  is  seen  the  fascial  investment  called  the  urogenital  trigone.  Behind  the  lower  edge 
of  the  trigone  lies  the  transversus  perinei  muscle  not  seen  in  the  drawing.  On  the  right  the  trigone 
and  transversus  perinei  have  been  removed.  The  bundle  of  muscle-fibers  which  constitute  the 
anterior  part  of  the  levator  ani  muscle  and  which  are  called  the  pubococcj^geus  muscle  can  be  seen. 
The  intersecting  involuntary  muscle-fibers  which  cross  between  the  two  pubococcygeus  muscles 
are  indicated  in  the  drawing.  Note  the  relationship  of  the  pubococcygeus  to  the  vagina  and  the 
sohincter  ani. 


supported  by  the  upward  and  forward  pressure  of  the  obturator  and  gluteal 
muscles  on  the  tissues  filling  the  ischiorectal  fossae.  Bearing  in  mind  this  rela- 
tion of  the  structures  of  the  pelvic  diaphragm  which  is  so  essential  to  its  proper 
action,  it  will  be  readily  seen  that  the  way  in  which  such  action  could  be  most 
easily  disturbed  would  be  by  injury  to  the  tissues  marking  the  junction  of  the 


INJUEIES    DUE    TO    CHILDBIRTH  493 

involuntary  muscle-fibers,  the  urogenital  trigone,  and  the  fascia  covering  the 
pubococcygeus.  It  is  at  this  point  that  lacerations  of  the  pelvic  floor  usually 
occur,  and  the  effect  of  such  injuries  is  measured  by  the  extent  to  which  the 
relations  of  the  various  structures  to  each  other  are  disturbed.  Figures  200-203 
give  a  diagrammatic  representation  of  the  effect  of  such  injuries.  A  laceration 
in  the  median  line  through  A  that  does  not  extend  below  the  upper  margin  of 
the  external  sphincter  involves  some  of  the  involuntary  muscle-fibers  and  causes 
little  disturbance  of  function  and  is  easily  repaired  at  the  time  of  injury.  Injury 
on  one  side  allows  the  pubococcygeus  on  that  side  to  sag  away  from  the  median 
line  by  the  detachment  of  the  involuntary  muscle-fibers.  If  the  tear  extends 
through  the  skin,  as  it  usuallj^  does,  the  relations  of  the  pubococcygeus  on 
that  side  to  the  external  sphincter  are  disturbed  and  the  sphincter  is  drawn 


Fig.   201. — Diagram  Showing  the  PrBococcTGEirs  Portion   of  the  Levator  Ani  Muscles, 

THE  Urogenital  Trigone,  and  the  External  Sphincter. 

B,  B,  junction  of  involuntary  muscle-fibers,  pubococcygeus,  and  urogenital  trigone. 

toward  the  uninjured  side.  The  deep  transversus  perinei  and  the  urogenital 
trigone  on  the  injured  side  retract,  pulling  the  pubococcygeus  fibers  outward, 
such  retraction  increasing  in  force  if  the  fascia  of  the  levator  ani  and  the  trigone 
are  separated  from  each  other.  If  the  tissues  on  both  sides  are  injured,  the  re- 
sulting disturbance  of  function  of  the  pelvic  diaphragm  is  more  marked,  the 
involuntary  fibers  are  torn  from  the  two  halves  of  the  pubococcygeus,  and  the 
muscles  sag  away  from  the  median  line  (Fig.  203).  The  retraction  of  the  trigone 
occurs  on  both  sides  and  the  external  sphincter  drops  downward  and  backward 
and  is  usually  drawn  toward  the  half  of  the  pubococcygeus  from  which  there 
is  the  least  separation  of  the  involuntary  fibers.  The  posterior  vaginal  wall 
drops  downward  and  backward  posterior  to  a  line  drawn  between  the  iscliial 
tuberosities. 


494  GYNECOLOGY 

When  these  injuries  occur  during  labor  they  allow  the  two  halves  of  the 
pubococcygeus  to  separate  as  the  birth  of  the  presenting  part  takes  place.     I 


I  iG.  202. — Laceration  Through  Right  Vaginal  Sulcus. 
On  the  left  the  relation  of  invgluntary  fibers,  pubococcygeus,  and  trigone  is  intact.     Note  that 
on  the  right  the  pubococcygeus  sags  away  toward  the  pubic  bone.     The  sphincter  is  drawn  toward 
the  unaffected  side. 


Fig.  203. — Laceration  Through  Both  Sulci  A  and  B. 

Both  pubococcygeus  muscles  together  with  the  urogenital  trigone  sag  outward  and  retract  toward 

the  pubic  bones.     The  external  sphincter  drops  backward  and  toward  the  least  injured  side. 

have  never  been  able  to  demonstrate  in  either  recent  or  old  lacerations  of  the 
pelvic  floor  the  rupture  of  the  fibers  of  the  pubococcygeus  that  is  so  graphically 


INJURIES    DUE    TO    CHILDBIRTH  495 

pictured  in  many  text-books,  and  do  not  believe  that  it  takes  place  except  in 
badly  executed  forceps  operations.  I  have  seen  cases  in  which  the  fibers  of  the 
pubococcygeus  were  torn  close  to  their  attachment  to  the  symphysis  during 
the  withdrawal  of  the  forceps  blades.  In  two  cases  where  brutal  attempts  at 
deUvery  by  forceps  had  been  made  the  fibers  of  the  pubococcygeus  were  torn 
above  the  sphincter  so  that  the  ischiorectal  fossa  was  opened.  I  believe  that  this 
opening  into  the  fossa  will  occur  whenever  the  fibers  of  the  pubococcygeus  near 
the  perineum  are  actually  ruptured. 

"The  effect  of  such  injuries  increases  in  direct  proportion  to  the  length  of 
time  during  which  they  are  allowed  to  remain  unrepaired  and  the  amount  of 
intra-abdominal  pressure  to  which  they  are  subjected.  The  muscles  atrophy 
from  impairment  of  function.     The  fascia  becomes  stretched  and  the  unsup- 


FiG.  204. — Laceration  Through  Sphincter. 
In  this  case  there  is  little  damage  to  the  pubococcygeus  and  trigone,  so  that  there  is  less  sagging 
and  retraction  than  when  the  laceration  has  taken  place  in  one  or  both  sulci.     It  is  also  possible  to 
have  a  laceration  both  through  the  sphincter  and  into  one  or  both  sulci. 

ported  action  of  the  sphincter  allows  the  posterior  vaginal  wall  and  the  rectal 
wall  beneath  it  to  prolapse.  The  gluteal  muscles  give  some  support  for  a  time 
by  pushing  upward  on  the  tissues  of  the  ischiorectal  fossae,  but  sooner  or  later 
the  fascia  of  the  levator  bounding  the  inner  walls  of  the  fossae  gives  way  under 
the  strain  and  the  upper  angles  of  the  fossae  become  flattened  and  the  support  of 
the  gluteal  muscles  is  lessened  or  withdrawn.  Where  the  tear  extends  through 
the  external  sphincter  and  its  function  is  eliminated  (Fig.  204)  the  sagging  of 
the  pubococcygeus  is  less  in  evidence  because  these  muscles  are  reHeved  of  the 
strain  necessary  for  the  maintenance  of  the  action  of  the  sphincter.  The  relaxa- 
tion of  the  pelvic  floor  occurring  in  nulliparae,  or  after  labor  in  which  there  has 
been  no  visible  tear  of  the  vaginal  waU,  is,  in  my  opinion,  due  to  stretching  or 
rupture  of  some  of  the  involuntary  fibers.    In  nulKparae  this  may  result  from  poor 


496 


GYNECOLOGY 


development  of  these  fibers,  as  it  often  occurs  where  the  genital  organs  are  also 
developed,  or  it  may  be  caused  by  overstrain  from  excessive  muscular  action 
causing  badly  directed  intra-abdominal  pressure." 

Symptoms. — The  symptomatology  of  lacerated  perineum  is  closely  inter- 
related with  that  of  cystocele  and  prolapse,  with  which  it  is  usually  associated 
as  a  part  of  a  general  process  of  relaxation.  The  role  played  by  the  lacerated 
perineum  in  the  symptoms  caused  by  this  chain  of  lesions  is  less  important 
than  that  of  cystocele  and  prolapse. 

NM.V.  Sxuve%. 


-CivisTocfcVe 


—  Conn.  lissTB<iJ)pe 


Fig.  205. — Complete  Laceration  of  the  Perineum,  Combined  with  Cystocele. 
In  this  case  a  connective-tissue  bridge  has  formed  between  the  ends  of  the  lacerated  sphincter, 
dimples,  that  indicati;  the  position  of  the  sphincter  ends,  are  shown. 


The 


Many  of  the  complaints  frequently  ascribed  to  lacerated  perineum,  such  as 
backache,  pelvic  pressure,  fatigue,  are,  in  reality,  due  chiefly  to  the  position  of 
the  uterus.  It  is  remarkable  how  little  discomfort  patients  may  experience 
from  extensive  laceration  of  the  perineum  and  rectocele  if  there  is  no  descensus 
of  the  uterus  or  cystocele.  Usually,  however,  the  loss  of  perineal  support  in- 
creases the  sense  of  weakness  and  pelvic  pressure. 


INJURIES    DUE    TO    CHILDBIRTH  497 

If  rectocele  is  present,  the  patient  is  annoyed  by  the  feeling  of  the  protruding 
mass.     Patients  with  rectocele  often  have  difficulty  in  defecation. 

Relaxation  of  the  perineum  frequently  produces  stasis  of  the  circulation 
about  the  sphincter,  causing  hemorrhoids,  which  are  usually  relieved  by  repair 
of  the  perineum.  If  the  laceration  includes  the  sphincter  muscle  the  result  is 
fecal  incontinence. 

Laceration  of  the  perineum  is  said  to  be  one  of  the  causes  of  sterility  as  a 
result  of  effluvium  seminis,  but  this  is  somewhat  doubtful. 

The  diagnosis  of  lacerated  perineum  is  made  by  the  touch  and  inspection. 
The  amount  of  laceration  is  best  judged  by  drawing  the  perineum  sharply  down- 
ward and  outward  by  inserting  the  two  forefingers  into  the  introitus.  This 
reveals  the  extent  of  damage, done  to  the  lateral  supports  of  the  rectum. 

If  a  complete  laceration  into  the  rectum  is  present,  the  bright-red  mucous 
membrane  of  the  gut  can  be  seen  rolling  outward,  just  below  the  posterior 
entrance  of  the  vagina.  The  ends  of  the  torn  sphincter  are  seen  as  well-marked 
dimples  on  each  side  of  the  anal  orifice. 

If  the  tear  does  not  extend  into  the  rectum,  but  only  includes  the  fibers  of 
the  sphincter  muscle,  the  anal  orifice  appears  flattened  and  thin  on  the  anterior 
or  vaginal  side.  The  characteristic  dimples  on  each  side  of  the  orifice  indicate 
clearly  the  position  of  the  two  ends  of  the  lacerated  muscle. 

The  treatment  of  lacerated  perineum  is  usually  only  one  step  in  connection 
with  several  other  procedures  in  repairing  the  damage  of  childbirth.  One  rarely 
simply  repairs  a  perineum,  for,  as  has  been  said,  it  is  nearly  always  associated 
with  cj^stocele  and  descensus  of  the  uterus.  There  are  innumerable  operations 
and  modifications  of  operations  for  the  repair  of  perineal  relaxation.  Some  of 
the  best  of  these  are  described  in  the  section  on  Operative  Surgery. 

If  the  view  of  the  pathologic  anatomy  of  perineal  laceration  described  above 
be  accepted,  the  principles  of  the  Emmet  operation  more  nearly  fulfil  the 
logical  requirenients  of  repair  than  do  any  of  the  others.  By  the  Emmet  method 
the  mucous  membrane  is  denuded  so  as  to  expose  the  areas  where  the  laceration 
took  place.  These  areas  we  have  seen  are,  first,  the  two  lateral  sulci,  where 
the  anterior  fibers  of  the  puborectales  were  torn  from  the  sides  of  the  rectal 
wall;  and,  second,  the  upper  part  of  the  central  raphe,  where  the  trans- 
versus  perinei  and  the  shoulders  of  the  two  sides  of  the  levator  ani  met  to  form 
the  perineal  body.  With  these  areas  exposed,  the  sutures,  when  placed  as  shown 
in  the  description  of  the  operation,  artificially  replace  the  ruptured  fibers  of  the 
puborectales,  and  thus  restore  the  lateral  support  of  the  rectum.  The  placing 
of  these  sutures  in  the  two  lateral  sulci  constitutes  the  first  part  of  the  operation. 
The  second  or  external  part  of  the  operation  consists  in  delivering  into  view,  the 
retracted  masses  of  the  levator  ani  and  transversus  perinei  muscles  and  suturing 
them  firmly  together.  When  rectocele  is  present  there  is  ncr  operation  com- 
parable mth  that  of  Emmet  for  reconstructing  the  perineum.  Most  other 
operations  are  directed  chiefly  to  the  restoration  of  the  muscular  perineal  body, 

32 


498  GYNECOLOGY 

but  pay  little  attention  to  restoring  the  lateral  support  of  the  rectum.  If 
there  is  little  or  no  rectocele  almost  any  one  of  the  operations  in  common  use  is 
efficacious  in  securing  a  good  result. 

The  operation  for  complete  laceration  of  the  perineum  is  simply  an  exten- 
sion of  the  perineal  operation,  the  denudation  being  carried  down  so  as  to  expose 
the  retracted  ends  of  the  torn  sphincter.  These  ends  are  delivered  into  view 
and  sutured  together  by  the  technic  described  on  page  649. 

VESICAL  FISTULA 

Fistulous  openings  connecting  the  bladder  with  the  genital  tract  are  made 
most  commonly  during  labor,  as  a  result  either  of  laceration  of  the  tissues  by 
instrumentation  or  from  prolonged  pressure  of  the  fetus,  with  consequent 
ischemia  and  necrosis  of  the  bladder  and  vaginal  walls.  In  the  present  days 
of  improved  obstetrics,  and  the  frequent  employment  of  Cesarean  section  when 
there  is  a  disproportion  between  the  size  of  the  child  and  the  capacity  of  the 
pelvis,  vesical  fistulse  from  labor  are  far  less  common  than  formerly.  On 
the  other  hand,  fistulse  resulting  from  injury  to  the  bladder  during  extensive 
pelvic  operations  are  more  common  on  account  of  the  greater  frequency 
with  which  such  operations,  especially  those  for  uterine  cancer,  are  being 
performed. 

Cancer  of  the  cervix  and  vagina  is  often  comphcated  in  the  later  stages  by 
vesical  fistulse.  They  are  sometimes  caused  by  the  curet  in  the  course  of  a 
palliative  operation  for  inoperable  cancer. 

In  recent  times  the  radium  treatment  of  uterine  and  vaginal  cancer  is  occa- 
sionally followed  by  fistulous  openings  in  the  vesicovaginal  septum,  which  may 
be  very  extensive.  Rarely  malignant  disease  of  the  bladder  and  syphilis  of  the 
bladder  or  vagina  result  in  fistula. 

Fistulous  communication  between  the  bladder  and  intestines  sometimes 
occurs  as  a  complication  of  some  destructive  disease  of  the  intestines,  where  the 
gut  has  become  adherent  to  the  bladder.  Examples  of  this  are  cancer,  tuber- 
culosis, and  diverticulitis  of  the  intestine.  Complicated  fistulous  tracts  be- 
tween the  viscera  are  sometimes  created  through  the  medium  of  pus-tubes  or 
infected  ovarian  cysts. 

Vesical  fistulse  are  classified  according  to  their  position. 

Vesicovaginal  fistula,  by  far  the  most  common  type,  imphes  an  opening  in 
the  vesicovaginal  septum. 

Vesicocervicovaginal  fistula  relates  to  a  comrnunication  between  the  bladder 
and  vagina  at  the  junction  of  the  vagina  and  cervix.  This  is  sometimes  termed 
a  juxtacervical  fistula. 

Vesico-uterine  or  intracervical  fistula  is  the  term  apphed  when  the  opening; 
is  into  the  cervical  canal,  so  that  the  urine  has  its  exit  through  the  internal  os. 
Urethrovaginal  fistula  is  a  communication  between  urethra  and  vagina. 


INJURIES    DUE    TO    CHILDBIRTH  499 

Enteravedcdl  fistula  implies  a  direct  or  indirect  opening  between  the  bladder 
and  intestines. 

The  size  of  fistulae  varies  from  that  of  a  hair  to  the  large  cavernous  openings 
such  as  are  sometimes  seen,  where  nearly  the  whole  vesicovaginal  septum  has 
been  destroyed. 

Long-standing  fistulse  are  apt  to  be  complicated  by  dense  contracting  adhe- 
sions which  immobilize  the  parts  and  render  plastic  repair  very  difficult. 

Symptoms. — The  essential  symptom  of  vesicogenital  fistula  is  involuntary 
leakage  of  urine,  which,  if  the  opening  is  large,  is  continuous,  whether  the  patient 
be  upright  or  lying  down.  If  the  opening  is  small,  or  if  folds  of  the  vagina  by 
chance  act  as  a  sort  of  valve,  the  leakage  may  occur  only  when  the  patient  is 
upright.  Such  patients  have  partial  or  complete  relief  at  night.  When  the 
fistula  is  very  small  the  leakage,  even  in  the  upright  position,  may  not  be  con- 
tinuous, but  may  occur  only  when  the  bladder  is  comparatively  full  or  after 
bodily  exertion  or  expulsive  acts,  like  coughing  and  sneezing.  In  such  cases  it 
is  difficult  to  differentiate  the  condition  from  functional  incontinence  due  to 
relaxation  of  the  internal  urethral  sphincter. 

Associated  with  the  urinary  incontinence  of  fistula  there  may  be  a  cystitis, 
with  inflammation  of  the  vagina  and  irritating  excoriation  of  the  vulva  and  sur- 
rounding parts  of  the  skin.  In  the  majority  of  cases,  however,  there  is  sur- 
prisingly little  inflammatory  reaction  either  in  bladder  or  vagina,  the  urine 
being  normal  and  the  epithelial  covering  of  vagina  and  vulva  showing  little 
evidence  of  chemical  irritation. 

Patients  with  vesical  fistulse  are  continuously  surrounded  with  a  urinous 
atmosphere  unless  the  most  unremitting  cleanliness  is  observed.  To  the  self- 
respecting  this  odor  is  a  source  of  distress  and  mental  depression. 

The  treatment  of  fistulse  is  entirely  surgical,  and  involves  a  delicate  operation 
for  closure  which  is  more  or  less  complicated,  according  to  the  position  of  the 
opening.     The  details  of  the  various  operations  are  given  in  Part  III. 

The  time  to  be  chosen  for  operation  is  a  matter  of  some  importance.  It  is, 
as  a  rule,  unwise  to  attempt  the  repair  of  a  fistula  at  once,  especially  one  which 
results  from  labor.  The  surgeon,  if  he  has  the  chance,  should  wait  until  the 
complete  involution  of  the  tissues  has  been  established,  but  not  long  enough  for 
serious  contractions  to  take  place  from  the  formation  of  scar-tissue.  The 
tissues  are  usually  most  favorable  for  operation  in  about  two  or  three  months 
after  labor.  Most  women  with  a  fistula  shrink  from  operation  for  a  long  time, 
so  that  the  surgeon  usually  has  no  choice  in  the  matter. 

The  diagnosis  of  the  average  case  of  fistula  is  simple,  but  when  the  opening 
is  very  smaU  it  is  sometimes  impossible  to  detect  it  by  inspection  in  the  folds 
of  the  vagina.  The  exact  location  should  always  be  determined  if  possible 
before  operation  is  attempted,  in  order  to  be  sure  that  the  case  is  not  one  of 
functional  urinary  incontinence.  This  can  usually  be  done  by  injecting  steril- 
ized milk  or  methyelene-blue  solution  into  the  bladder  and  observing  it  as  it 


500  GYNECOLOGY 

leaks  out  into  the  vagina.  In  cases  where  there  is  leakage  only  when  the  patient 
is  standing,  methylene-blue  solution  is  injected  into  the  bladder  and  pledgets  of 
cotton  placed  in  the  vagina.  The  patient  is  requested  to  walk  about  or  make 
some  physical  exertion,  when  the  pledgets  of  cotton  are  removed.  That  one 
which  is  in  contact  with  the  fistulous  opening  will  indicate  its  location  by  the 
blue  staining. 

The  diagnosis  should  always  be  confirmed  by  a  cystoscopic  examination, 
which  also  determines  the  relation  of  the  fistula  to  the  ureteral  openings. 

ABDOMINAL    HERNIA 

Abdominal  hernia  is  so  much  more  common  in  women  than  in  men  and  is  so 
frequently  induced  by  child-bearing  that  it  must  be  included  as  a  gynecologic 
disease.  Hernial  condition  of  the  abdomen,  aside  from  those  hernias  which 
involve  the  inguinal  and  femoral  regions,  may  be  divided  into  three  classes:  (1) 
Diastasis  of  the  recti  muscles,  (2)  umbihcal  hernia,  and  (3)  postoperative  hernia 
of  wounds. 

Diastasis  of  the  recti  muscles  is  an  extremely  common  affection  and  is  nearly 
always  the  result  of  child-bearing.  Occasionally  it  is  the  result  of  long-existing 
pelvic  tumors  which  are  large  enough  to  distend  the  abdomen.  In  some  cases 
it  is  caused  by  adiposity.  Its  presence  depends,  to  a  certain  extent,  on  a  pre- 
existing physiologic  deficiency  of  tissue  and  constitutional  muscular  weakness, 
for  it  is  sometimes  seen  to  a  very  marked  degree  in  women  who  have  borne 
only  one  child,  while  other  women  who  have  had  many  children  show  no  signs 
of  it.  Other  things  being  equal,  however,  frequent  child-bearing  is  a  common 
etiologic  factor.  It  is  much  more  common  among  the  poor  and  ill-nourished 
than  among  the  well-to-do.  This  is  doubtless  due  partly  to  diminished  muscu- 
lar tone  and  partly  to  the  necessity  of  hard  work  during  pregnancy  and  soon 
after  dehvery — work  that  is  usually  done  with  little  or  no  artificial  abdominal 
support.  Diastasis  of  the  recti  is  seen  most  commonly  in  the  very  thin  and  very 
fat,  owing  to  the  fact  that  in  both  types  of  women  the  abdominal  muscles  are 
diminished  in  supporting  power.  It  is  most  frequently  seen  in  women  who 
show  other  evidences  of  the  injuries  of  childbirth — i.  e.,  retroversion,  prolapse, 
and  relaxation  of  the  vaginal  outlet. 

The  separation  of  the  muscles  in  diastasis  is  always  most  marked  at  the 
level  of  the  umbilicus,  and  extends  for  varying  distances  both  above  and  below 
this  point,  the  extreme  being  a  complete  disunion  of  the  two  muscles  from 
pubes  to  ensiform  cartilage.  The  width  of  the  separation  varies  from  1|  to  4,  5, 
or  even  6  inches. 

In  cases  of  simple  diastasis  there  is  no  definite  hernial  ring.  When  ab- 
dominal pressure  is  exerted  a  longitudinal  protrusion  is  seen  in  the  center,  of 
the  abdomen,  always  including  the  umbilical  region.  On  each  side  of  the 
hernial  protrusion  can  be  felt  the  edges  of  the  recti  muscles.     The  condition  is 


INJURIES    DUE    TO    CHILDBIRTH  501 

often  recognizable  simply  from  inspection  of  the  abdomen,  especially  if  the 
patient  is  thin.  It  can  be  made  evident  by  placing  the  hand  on  the  abdomen 
and  asking  the  patient  to  cough.  A  still  better  way  to  bring  the  protrusion  into 
prominence  is  to  ask  the  patient  while  Ijang  on  her  back  to  raise  herself  to  a 
semisitting  position.  In  the  effort  to  assume  this  position  the  recti  muscles  are 
brought  into  rigid  contraction  and  the  intestinal  contents  are  forced  out  be- 
tween them.  When  the  patient  is  standing  there  is  a  characteristic  sagging  of 
the  lower  abdomen,  especially  if  the  patient  is  fat.  In  thin  patients  the  contour 
is  much  like  that  of  asthenic  ptosis. 

The  chnical  significance  of  diastasis  of  the  recti  muscles  is  much  greater 
than  is  commonly  recognized.  To  the  gynecologist  it  represents  one  of  the 
numerous  injuries  from  childbirth,  equal  in  importance  to  laceration  of  the  peri- 
neum or  displacement  of  the  uterus.  The  symptoms  of  the  condition  are  not 
always  entirely  definite.  Together  with  other  tissue  relaxations  from  child- 
birth, it  causes  exhaustion  after  effort  and  general  lassitude.  Its  most  char- 
acteristic sjnnptom  in  fat  individuals  is  pain  in  the  loins.  This  is  due  to 
compensatory  strain  on  the  lateral  muscles  of  the  trunk  on  account  of  the 
deficient  abdominal  support.  Dorsal  backache  is  also  very  common.  The  di- 
gestive and  neurotic  sjanptoms  that  characterize  asthenic  ptosis  are  often  seen 
in  women  with  diastasis,  in  whom  there  exists  a  so-called  acquired  ptosis  of 
the  abdominal  contents  quite  similar  to  that  of  the  congenital  type. 

The  treatment  of  diastasis  of  the  recti  muscles  is  either  orthopedic  or  surgical. 
Orthopedic  treatment  consists  in  the  application  of  an  efficient  abdominal  sup- 
port.    This  is  best  accomplished  by  a  perfectly  fitting  corset. 

A  cure  of  the  condition  can  only  be  gained  by  a  surgical  operation.  In 
most  cases  this  is  feasible  unless  there  is  some  constitutional  contra-indication 
to  surgery  or  unless  the  patient  is  too  fat.  In  the  enormously  fat,  where  there 
is  great  abdominal  tension,  the  operation  is  attended  with  more  than  average 
danger  of  postoperative  complications.  Most  cases  of  diastasis  are  encountered 
in  women  who  need  general  repair  for  the  injuries  of  childbirth.  There  is  empha- 
sized in  the  discussion  of  these  injuries  (see  above)  the  great  importance  of 
neglecting  no  single  link  in  the  chain  of  weakened  structures,  and  in  carrying 
out  this  plan  the  relaxed  abdomen  must  be  considered  with  the  other  lesions. 

Inasmuch  as  in  most  of  the  cases  of  general  relaxation  the  abdomen  must 
be  opened,  opportunity  is  given  to  test  the  condition  of  the  recti  muscles.  This 
is  done  after  making  the  incision  by  grasping  the  abdominal  wall  in  the  direction 
of  the  umbihcus  (see  Fig.  432),  by  which  the  edges  of  the  recti  can  easily  be  felt, 
and  if  they  be  separated  the  thin  intervening  membrane,  composed  of  fascia  and 
peritoneum,  is  made  evident. 

The  operation,  as  performed  by  the  author,  consists  in  reduplicating  the 
aponeurosis  at  the  level  of  and  above  the  umbihcus,  so  that  the  bellies  of  the  recti 
muscles  become  contiguous.  Below,  the  layers  of  the  abdominal  wall  are  ap- 
proximated in  the  usual  way.     For  a  description  of  the  operation,  see  page  771. 


,/ 


502  GYNECOLOGY 

UMBILICAL  HERNIA 

As  stated  above,  umbilical  hernia  is  far  more  common  in  women  than  in 
men  because  of  the  number  of  cases  directly  due  to  child-bearing. 

It  is  not  always  possible  to  draw  a  distinct  line  between  diastasis  of  the 
recti  muscles  and  umbilical  hernia.  It  must  be  emphasized  primarily  that  in 
all  cases  of  umbiHcal  hernia  there  exists  a  greater  or  less  degree  of  diastasis. 

In  typical  umbihcal  hernia  there  is  a  distinct  ring,  with  a  well-defined  hernial 
sac,  while  in  diastasis  there  is  a  general  protrusion  in  the  space  between  the 
recti  muscles  without  a  specific  ring  or  pouch.  In  large  or  recurrent  umbiHcal 
hernias  the  two  conditions  sometimes  merge. 

In  umbiHcal  hernia  there  is  a  great  tendency  on  the  part  of  the  intestines 
and  omentum  to  become  adherent  to  the  ring  and  inner  lining  of  the  sac.  In 
simple  diastasis  adhesions  are  usually  absent. 

On  account  of  the  adhesions  and  ring  formation  of  umbiHcal  hernia  intes- 
tinal obstruction  is  always  a  threatening  danger,  which  does  not  need  to  be 
regarded  in  simple  diastasis. 

The  size  of  umbilical  hernias  varies  from  a  small  protrusion  of  the  umbiHcus 
to  colossal  sacs  which  contain  most  of  the  intestines. 

The  symptoms  of  umbilical  hernia  include  those  of  the  diastasis  of  the 
recti,  which  is  always  present.  In  addition  are  usually  pains  and  abdominal 
discomfort  due  to  the  adhesions  of  the  bowel  and  omentum.  If  incarceration 
or  strangulation  takes  place,  intense  pain,  vomiting,  obstipation,  and  the  various 
other  symptoms  of  acute  obstruction  ensue.  Umbilical  hernias  are  not  as  liable 
to  strangulation  as  are  inguinal  and  postoperative  hernias. 

The  smaller  hernias  are  entirely  obvious  and  easy  of  diagnosis,  but  the  larger 
hernias,  in  which  the  protrusion  of  the  umbiHcus  has  become  fused  with  the 
general  sac,  often  cause  confusion.  These  patients  are  usually  fat  and  often 
present  an  immense  abdominal  enlargement,  which  frequently  eHcits  the  diag- 
nosis of  abdominal  tumor,  usually  of  ovarian  cyst.  Often  these  patients  are 
credited  with  being  much  fatter  than  they  really  are,  the  hernial  protrusion 
being  regarded  as  a  huge  mass  of  fat,  whereas,  in  reality,  there  may  be  very  Httle 
fat  between  the  skin  of  the  abdomen  and  the  intestines. 

The  treatment  of  umbilical  hernia  is  surgical  unless  there  is  some  constitu- 
tional contra-indication,  or  unless  the  chances  of  success  are  too  small  to  warrant 
subjecting  the  patient  to  the  risk  of  operation. 

The  operation  for  the  large  hernias,  especially  in  very  fat  women,  is,  without 
doubt,  a  dangerous  one.  On  account  of  the  great  size  of  the  wound  and  the 
inevitable  necrosis  and  dissolution  of  fat  tissue,  there  is  special  danger  of  local 
sepsis.  Pneumonia  and  embolism  are  other  compHcations  that  are  especially 
apt  to  occur.  In  addition  to  this  must  be  taken  into  account  also  the  possi- 
bility of  a  recurrence,  which,  if  it  does  take  place,  usually  results  in  a  condition 
worse  than  that  of  the  original  hernia. 


INJURIES   DUE   TO    CHILDBIRTH 


503 


If  the  operation  is  inadvisable,  the  only  course  is  the  application  of  an  ab- 
dominal support,  the  proper  fitting  of  which  requires  great  skill  and  experience. 
The  best  form  of  support  is  a  perfectly  fitting  corset,  but  there  are  few  who  are 
able  to  fit  a  satisfactory  corset  to  some  of  these  very  stout  patients. 

The  surgical  treatment  for  umbihcal  hernia  is  given  on  page  775,  where  the 
longitudinal  and  transverse  types  of  operation  are  described. 

The  longitudinal  operation  has  for  its  basis  the  approximation  in  the  middle 
line  of  the  separated  recti  muscles. 

The  principle  of  the  transverse  operation  is  the  overlapping  of  the  aponeu- 
rosis transversely. 

The  results  of  operations  for  umbihcal  hernia  depend  somewhat  on  the 
skill  and  ingenuity  of  the  operator,  but  even  with  the  best  workmanship  a  certain 
percentage  of  recurrences  is  met  with. 

POSTOPERATIVE  HERNIA 

In  the  present  days  of  improved  asepsis  and  operative  technic  postoperative 
hernias  in  abdominal  wounds  are  comparatively  uncommon,  yet  they  still  occur 
with  sufficient  frequency  to  be  a  matter  of  chagrin.  Postoperative  hernia  is 
usually  the  result  either  of  incomplete  closure  of  the  wound  or  of  wound  sepsis, 
which  in  healing  has  left  a  point  of  weakness  in  the  scar.  By  incomplete  closure 
of  the  wound  it  is  meant  that  there  has  been  drainage,  or  that  in  sewing  up  the 
wound  the  surgeon  has  failed  to  secure  perfect  coaptation  of  the  layers.  Another 
class  of  cases,  and  a  very  important  one,  is  that  in  which  an  incision  has  been 
made  through  an  abdominal  wall  already  weakened  by  a  diastasis  of  the  recti 

muscles. 

Postoperative  hernia  usually  makes  its  first  appearance  as  a  small  protru- 
sion under  the  skin,  to  one  side  of  or  above  the  cutaneous  scar.  It  is  slightly 
tender,  and  transmits  an  impulse  when  the  patient  coughs.  If  the  hernia  is  not 
attended  to,  it  grows  gradually  larger,  finally  involving  the  area  about  the 
wound  and  extending  outward  and  upward  over  the  abdomen.  The  hernia 
may  consist  of  a  single  rounded  mass,  representing  the  protrusion  of  the  bowel 
or  omentum  through  a  single  ring;  or  it  may  be  extremely  irregular  as  the  result 
of  a  complex  hernial  formation  of  numerous  rings  and  sacs  honeycombing  the 
abdominal  wall.  The  content  of  the  hernial  sacs,  especially  in  the  complex 
type,  usually  consists  of  omentum,  one  of  the  functions  of  which  is  to  precede 
the  bowel  and  to  prevent  its  entrance  through  the  breach  in  the  abdominal  wall. 
The  protecting  omentum  nearly  always  becomes  adherent  to  the  ring  and  inner 
surface  of  the  sac.  It,  however,  may  fail  to  block  the  entrance  of  the  intes- 
tine, especially  when  the  ring  has  been  stretched  to  a  considerable  size,  and  the 
condition  then  becomes  more  serious. 

The  omental  tissue  contained  within  the  hernial  sac  usually  becomes  hyper- 
trophied,  and  this  process,  together  with  the  formation  of  adhesions,  prevents 


504  GYNECOLOGY 

complete  manual  reduction  of  the  hernia.  It  sometimes  happens  that  the 
omental  mass  becomes  strangulated  and  necrotic,  in  which  case  there  can  be 
felt  in  the  abdominal  wall  a  hard  tender  mass  without  symptoms  of  intestinal 
obstruction,  but  with  constitutional  evidence  of  toxic  absorption.  If  a  portion 
of  the  intestine  is  included  in  the  sac  it  may  become  obstructed.  Postoperative 
hernias  are  more  dangerous  than  umbilical  hernias  as  regards  serious  complica- 
tions. 

The  diagnosis  of  postoperative  hernia  is  usually  simple,  but  not  always. 
In  one  of  the  author's  cases  a  mass  in  the  abdomen  lying  beneath  the  scar, 
and  diagnosed  as  a  strangulated  omental  hernia,  proved  to  be  an  implantation 
metastasis  following  an  operation  for  adenocarcinoma  of  the  uterine  body. 
In  another  case  the  lump  in  the  abdomen,  diagnosed  as  postoperative  hernia, 
turned  out  to  be  an  adenomyoma  growing  from  one  of  the  round  ligaments 
which  at  the  previous  operation  had  been  crossed  and  sewed  together  in  the 
middle  line,  according  to  Mayo's  modification  of  Gilliam's  operation. 

Treatment. — Extreme  care  in  closing  abdominal  wounds  is  one  of  the  main 
duties  of  the  surgeon,  for  on  this  depends  chiefly  the  prevention  of  postopera- 
tive hernia.  In  operating  for  pelvic  conditions  that  require  drainage  the 
gynecologist  is  particularly  fortunate  in  being  able  to  drain  through  the  vagina, 
which  not  only  is  excellently  adapted  for  the  purpose  by  its  position,  but  is  also 
practically  exempt  from  the  danger  of  hernia.  Only  in  the  most  serious  forms 
of  pelvic  suppuration  is  it  necessary  to  drain  through  the  abdominal  wall. 
Thus,  one  of  the  most  common  causes  of  postoperative  hernia  of  the  earlier  days 
is  almost  eliminated  by  improved  methods  of  pelvic  drainage. 

In  closing  the  wound  after  a  pelvic  operation  the  observance  of  a  number 
of  technical  principles  is  valuable.  It  is  an  excellent  plan  just  before  sewing 
the  peritoneum  to  reach  into  the  upper  part  of  the  abdomen  and  pull  the  omen- 
tum down,  spreading  it  like  an  apron  over  the  bowels  which  lie  just  beneath 
the  wound.  If  adhesions  form  along  the  inner  scar  they  will  be  with  the  omen- 
tum and  not  the  intestines.  If  a  rupture  occurs  in  the  course  of  the  scar,  the 
omentum  is  by  this  means  enabled  to  enter  the  breach  first.  It  is  not  unlikely 
that  the  adhesions  that  sometimes  form  along  the  peritoneal  side  of  the  wound 
are  themselves  conducive  to  weakening  the  scar.  In  order  to  prevent  this 
great  care  should  be  exercised  not  only  in  the  matter  of  asepsis,  but  in  avoiding 
trauma  of  the  edges  of  the  abdominal  incision.  Numerous  methods  are  em- 
ployed to  insure  this.  Some  use  towels  or  gauze  or  sheet-rubber  to  protect  the 
edges.  There  is  some  question  whether  these  do  not  often  do  more  harm  than 
good.  The  best  prophylactic  is  the  considerate  handling  of  the  tissues,  a  rule 
that  is  applicable  not  only  in  this  particular  instance,  but  in  the  whole  field  of 
surgery. 

In  sewing  the  peritoneum  care  must  be  taken  to  secure  a  smooth  perfect 
coaptation  without  gaps,  especially  at  the  ends  of  the  incision. 

The  approximation  of  the  bellies  of  the  recti  muscle  is  an  important  step  in 


INJURIES    DUE    TO    CHILDBIRTH  505 

closing  an  abdominal  wound  and  one  that  is  too  often  regarded  as  unnecessary. 
The  muscles  are  brought  together  by  a  few  deeply  placed  catgut  sutures  tied 
only  tight  enough  to  secure  approximation.  Numerous  good  methods  of  sewing 
the  fascia  are  in  use,  some  of  which  secure  an  edge-to-edge  union,  while  others 
employ  the  method  of  overlapping.  As  fascia  tissue  readily  heals  to  fascia  tissue 
any  method  which  ensures  a  strong  and  perfect  approximation  of  the  fascial 
surfaces,  especially  at  the  ends  of  the  incision,  meets  the  requirements. 

As  has  been  stated,  one  of  the  causes  for  postoperative  hernia  is  a  previously 
existing  diastasis  of  the  recti  muscles.  It  is  very  essential  that  this  should  be 
recognized  and  repaired  during  the  course  of  the  operation.  This  point,  insuffi- 
ciently recognized  by  abdominal  surgeons,  has  been  emphasized  by  Webster. 
The  condition  is  especially  to  be  sought  for  in  operating  on  muciparous  women 
and  after  the  removal  of  large  tumors. 

The  operation  for  postoperative  hernia  follows  the  technic  of  that  em- 
ployed for  umbiHcal  hernia,  the  basic  principle  of  which  is  that  the  recti  muscles 
must  be  approximated  a  considerable  distance  from  the  hernial  ring  in  order  to 
give  adequate  support  to  the  new  scar  (see  page  782). 

Postoperative  hernias  following  operations  for  hernias  are  discouraging 
catastrophes,  for  the  recurrent  hernia  is  usually  far  worse  than  the  original  one. 


SPECIAL    GYNECOLOGIC    DISEASES 
ECTOPIC  PREGNANCY 

Ectopic  pregnancy  relates  to  those  conditions  in  which  the  nidation  and 
growth  of  the  impregnated  ovum  take  place  elsewhere  than  in  the  uterine 
cavity.  The  ovum  may  become  implanted  in  the  tube,  in  the  ovary,  or  on  the 
peritoneum  of  the  abdominal  cavity.  If  the  ovum  develops  in  that  part  of  the 
tubal  canal  which  is  included  in  the  wall  of  the  uterus  the  condition  is  termed  an 
"interstitial  pregnancy." 

In  by  far  the  greater  number  of  cases  ectopic  pregnancy  takes  place  in  the 
tube  and  usually  in  the  outer  half  of  the  tube. 

The  ovum  when  expelled  from  the  corpus  luteum  of  the  ovary  is  sheltered 
and  guided  to  the  tubal  canal  or  -oviduct  by  the  fimbriae,  and  is  passively  con- 
ducted to  the  uterus  probably  by  the  motion  of  the  cilia  that  adorn  the  epi- 
thehum  of  the  fining  mucous  membrane  and  by  peristaltic  movements  of  the 
tube  wall.  The  passage  of  the  ovum  to  the  uterine  canal  occupies  several  days, 
possibly  a  week,  and  it  is  at  the  beginning  of  or  during  the  journey  that  the 
ovum  becomes  impregnated  by  union  with  a  spermatozoon.  Under  normal 
conditions  the  fertilized  egg  continues  its  course  until  it  reaches  the  uterine 
cavity,  where  it  embeds  itself  in  the  endometrium  and  proceeds  to  develop. 

Causes. — Tubal  implantation  bespeaks  some  impediment  to  the  ovum  in  itK 
passage  to  the  uterus.  There  are  several  causes  for  this  interruption,  some  of 
which  are  sufficiently  obvious.  The  frequency  with  which  tubal  pregnancy  is 
found  in  tubes  that  have  been  damaged  by  inflammatory  processes,  such  as 
result  from  gonorrhea  and  puerperal  infection,  is  evidence  that  the  interruption  is 
the  outcome  either  of  destruction  of  the  cifiated  surface  epithefium  or  of  adhesions 
to  the  external  surface  of  the  tube  which  prevent  its  normal  peristalsis.  Thus, 
tubal  pregnancy  may  result  either  from  salpingitis  or  perisalpingitis.  An  acute 
appendicitis,  the  peritoneal  infection  of  which  extends  to  the  tube  and  causes 
adhesions,  may  in  the  same  manner  be  the  indirect  cause  of  a  later  tubal  preg- 
nancy. 

The  ovum  may  find  its  way  into  a  diverticulum  of  the  tube  or  into  an  acces- 
sory tube,  and,  becoming  embedded  there,  develop  an  ectopic  pregnancy. 

The  foregoing  are  anatomic  causes  which  can  often  be  incontestably 
demonstrated.  Many  times,  however,  this  cannot  be  done,  and  the  etiology 
then  becomes  a  matter  of  speculation.  Many  theories  have  been  advanced,  some 
of  them  being  worthy  of  note. 

Sippel  bases  his  theory  of  causation  from  observations  that  the  ovum  may 
enter  the  tube  on  the  side  opposite  to  the  ovary  from  which  it  has  been  dis- 

506 


SPECIAL   GYNECOLOGIC   DISEASES  507 

charged.  This  is  exemplified  in  cases  of  right-sided  tubal  pregnancy  with  a 
corpus  luteum  verum  of  the  left  ovary,  -or  when  pregnancy  has  occurred  after  a 
,  pelvic  operation,  in  which  the  tube  from  one  side  and  the  ovary  from  the  other 
have  been  removed.  Sippel  assumes  that  the  impregnated  ovum  during  the 
time  occupied  by  this  long  journey  across  the  pelvis  becomes  too  large  to  be 
moved  along  the  tube  to  the  uterus.  It  is  assumed,  also,  that  after  a  certain 
period  the  trophoblastic  layer  of  the  egg  begins  to  exert  its  corroding  influence 
on  the  maternal  epithehum — the  first  step  toward  nidation.  Under  normal 
conditions  this  period  is  not  reached  until  the  egg  arrives  at  the  uterine  canal, 
but  it  may  well  be  imagined  that  the  time  taken  to  travel  to  the  opposite  tube 
may  bring  the  ovum  to  the  corroding  point  while  still  in  the  tube.  It  then 
sinks  into  the  subepithelial  tissue  of  the  mucous  membrane  and  its  journey  is  at 
an  end. 

Freund  has  advanced  the  hypothesis  that  the  conditions  mentioned  in 
Sippel's  theory  may  result  from  the  unusual  length  and  convolutions  of  the  tube, 
such  as  obtains  in  the  infantile  type. 

Another  theory  for  the  etiology  of  extra-uterine  pregnancy  in  normal  tubes  has  been  ad- 
vanced by  Katz.  He  has  found  that  in  pregnancy  a  definite  change  takes  place  in  the  mucous 
membrane  of  the  tubes.  The  cylindric  ciUated  epithelial  cells  become  markedly  increased 
and  heaped  up  on  each  other  and  lose  their  cilia.  During  menstruation  the  same  process  takes 
place,  though  in  a  less  degree.  Katz  ascribes  this  change  to  the  influence  of  the  inner  secretion 
of  the  corpus  luteum.  He  thinks  that  this  heaping  up  of  the  surface  epitheUum  and  the  loss 
of  the  cflia,  may  act  as  a  hindrance  to  the  normal  passage  of  the  ovum  through  the  duct.  Thus 
he  imagines  that  if  an  ovum  were  impregnated  near  the  ovary  it  might  have  some  difficulty  in 
negotiating  the  route  thus  impeded  and,  becoming  discouraged,  settle  down  and  develop  in  the 
folds  of  the  mucous  membrane  of  the  tube.  There  may  be  some  merit  in  this  explanation, 
especially  when  one  considers  that  most  extra-uterine  pregnancies  take  place  in  the  outer  half 
of  the  tube.  It  would  seem  at  least  reasonable  to  suppose  that  the  abnormal  impregnation 
might  be  due  to  an  aberration  of  some  normal  physiologic  function. 

When  a  fertilized  ovum  becomes  implanted  in  the  tube  it  is  destined  to  early 
destruction,  usually  within  the  first  three  months,  although  cases  have  been 
known  where  it  has  gone  to  complete  development.  The  death  of  the  embryo 
is  due  to  the  poor  soil  in  which  the  egg  has  been  inserted.  The  tissue  of  the 
wall  of  the  tube  is  capable  of  only  a  small  decidual  reaction,  so  that  the  fetal 
tissue  is  improperly  nourished.  The  wall  of  the  tube,  under  the  influence  of  the 
growth  of  the  ovum  and  the  general  softening  with  which  pregnancy  affects 
all  the  pelvic  organs,  becomes  thinner  and  softer  and  is  easily  ruptured. 

Rupture  of  the  surrounding  capsule  causes  the  death  of  the  fetus  and  sub- 
jects the  mother  to  grave  danger.  If  the  bleeding  is  free  and  unconfined  the 
hemorrhage  may  be  fatal  in  a  short  time,  but  if  the  bleeding  is  impeded  the  blood 
becomes  coagulated  and  a  hematocele  forms.  The  latter  process  more  com- 
monly takes  place. 

Two  pathologic  forms  are  recognized  as  having  special  clinical  manifesta- 
tions— tubal  rupture  and  tubal  abortion. 


508  GYNECOLOGY 

Tubal  rupture  is  applied  to  the  condition  in  which  the  outer  wall  of  the 
tube  constituting  the  external  capsule  of  the  ovum  ruptures  and  allows  the 
maternal  blood  to  flow  unimpeded  into  the  peritoneal  cavity.  This  gives  rise 
to  the  classical  picture  of  sudden  collapse  and  tragic  death.  Fortunately,  tubal 
rupture  is  not  nearly  so  common  as  tubal  abortion.  In  tubal  abortion  rupture 
takes  place  in  the  fetal  capsule,  but  not  in  the  wall  of  the  tube  itself.  The  blood, 
therefore,  is  confined  by  the  tubal  wall  to  a  certain  extent,  and,  being  under 
restraint,  flows  less  rapidly,  time  being  given  for  clotting.  In  this  way  a  hema- 
toma is  formed  in  the  interior  of  the  tube,  and  is  termed  a  "tubal  mole"  or  "hema- 
tosalpinx." The  hemorrhage  may  be  entirely  confined  to  the  tube,  though  the 
blood  may  in  some  cases  flow  freely  from  the  ostium  of  the  tube  and  cause  col- 
lapse and  death,  as  in  tubal  rupture.  It  more  commonly  trickles  slowly  into  the 
peritoneal  cavity,  creating  a  large  hematocele.  Usually  this  hematocele  is 
formed  in  the  pouch  of  Douglas,  where  it  can  readily  be  felt  by  vaginal  examina- 
tion. At  first  it  is  soft  and  doughy,  but  in  the  course  of  time  a  semi-organized 
capsule  forms  around  the  mass,  so  that  to  the  vaginal  touch  it  is  firm  and  well 
defined,  often  resembling  an  ovarian  tumor. 

If  the  posterior  culdesac  is  obhterated  by  adhesions  the  blood-mass  may 
accumulate  in  front  of  the  uterus  or  higher  up  in  the  abdominal  cavity. 

The  blood-mass  which  coflects  outside  of  the  tube  is  termed  a  "pelvic  hema- 
tocele." The  leaking  of  blood  from  the  tube  may  continue  over  a  considerable 
period  of  time,  so  that  an  enormous  hematocele  may  form,  filling  the  pelvis  and 
the  lower  part  of  the  abdominal  cavity. 

These  hematoceles  present  an  excellent  medium  for  the  growth  of  bacteria, 
and  if  they  become  infected,  sometimes  develop  most  extensive  and  destructive 
abscesses. 

The  most  marked  instances  of  infection  are  seen  in  women  who,  thinking 
themselves  normally  pregnant,  attempt  abortion. 

Infection  of  tubal  or  pelvic  hematoceles  may  also  result  from  vaginal  punc- 
ture under  the  mistaken  diagnosis  of  pus-tubes. 

After  rupture  the  embryo  and  all  the  fetal  tissue  are  rapidly  absorbed. 
Nothing  is  seen  of  them  in  the  majority  of  specimens  removed  by  operation. 
On  account  of  this  disappearance  of  fetal  tissue  the  question  is  sometimes  raised 
whether  a  small  hematosalpinx  is  the  result  of  bleeding  from  ectopic  gestation 
or  from  some  other  cause.  Doubtless  in  rare  instances  a  hematoma  may  be 
formed  in  the  tube  by  inflammatory  processes.  It  is  so  unusual,  however,  that 
a  hematosalpinx  is  ordinarily  assumed  to  be  the  result  of  a  tubal  abortion, 
Veit  asserts  that  patency  of  the  tubal  ostium  is  evidence  of  ectopic  pregnancy, 
while  if  it  is  sealed  the  bleeding  is  probably  from  inflammatory  ulceration.  It  is 
very  doubtful  if  this  is  a  reliable  test. 

The  development  of  a  tubal  pregnancy  produces  a  decidual  reaction  in  the 
endometrium  of  the  uterus  similar  to  that  following  a  normal  pregnancy. 

At  the  time  of  rupture  of  the  tubal  sac  bleeding  from  the  endometrium 


SPECIAL   GYNECOLOGIC   DISEASES 


509 


takes  place,  continuing  until  the  termination  of  the  tubal  pregnancy.  This 
decidua  desquamates  away  from  the  uterine  wall,  and  appears  as  shreds  of  formed 
tissue  in  the  vaginal  discharge;  sometimes  it  comes  away  as  a  complete  cast  of  the 
uterine  canal. ^ 

It  has  long  been  a  matter  of  doub.t  whether  the  uterine  bleeding  associated 
with  ectopic  pregnancy  is  a  part  of  the  tubal  hemorrhage  flowing  backward 
through  the  uterine  ends  of  the  tubes,  or  whether  it  issues  from  both  sources. 
The  recent  work  of  Sampson  seems  to  have  definitely  settled  this  point.  By 
means  of  injecting  uteri,  removed  for  tubal  pregnancy,  he  has  shown  that  the 
uterine  bleeding  in  all  cases  is  venous  in  origin  and  arises  from  the  endometrium, 
and  that  in  no  case  does  it  escape  from  the  tube  into  the  uterine  cavity. 


N«.^  St  cMa  a  AjiffT 


1  iG.  206. — Tubal  Pregnancy.     Hematosalpinx. 
The  dark-colored  tube  distended  with  blood-clot  is  seen.     There  are  adhesions  on  the  surface. 
The  ovary  has  been  included  in  the  adhesions  and  lacerated  in  its  removal.     For  purposes  of  clearer 
illustration  the  uterus  and  other  adnexa  have  been  added  in  the  drawing. 


In  all  cases  of  ectopic  pregnancy  the  uterus  is  increased  to  the  size  that  it 
attains  under  the  influences  of  normal  pregnancy  at  about  two  months.  Samp- 
son has  shown  that  this  enlargement  is  due  to  the  thickening  of  the  endometrium 
and  the  hyperemia  of  the  organ,  there  being  much  doubt  as  to  any  increase  in 
the  musculature.  The  bleeding  results  from  the  venous  congestion  in  the 
endometrium.  The  enlargement  of  the  uterus  and  the  bleeding  continue  until 
the  abortion  of  the  tube  is  complete,  when  involution  takes  place,  as  it  does 

^  Ectopic  decidua  has  been  observed  on  and  in  the  ovary,  on  the  peritoneum  of  the  uterus 
(mostly  its  posterior  surface),  on  the  pelvic  peritoneum  (especially  in  Douglas'  pouch),  more  rarely 
on  the  parietal  pelvic  peritoneum,  on  the  anterior  wall  of  the  uterus,  the  vesico-uterine  space,  on  the 
ligaments  of  the  uterus,  on  the  omentum,  the  small  intestine,  the  vermiform  appendix,  on  the  mucous 
membrane  of  the  tube  even  in  intra-uterine  pregnancy,  in  the  cervix  and  vagina,  in  polyps,  adeno- 
metritic  foci,  proliferating  scars,  and  on  adhesive  bands,  and  very  rarely  on'the  peritoneum  of  the 
tube.  According  to  Meyer,  it  is  not  a  physiologic  condition.  The  chief  factor  in  its  causation  is 
probably  a  preceding  inflammation.      (Moraller,  abstract  from  R.  Meyer.) 


510 


GYNECOLOGY 


after  complete  abortion  of  uterine  pregnancy.  The  separation  of  the  decidua 
is  the  result  during  the  subinvolution  period  of  venous  extravasation  of  blood 
between  the  inner  and  outer  layers  of  the  endometrium  by  which  the  outer 
compact  layer  is  expelled. 

Symptoms. — There  are,  as  a  rule,  no  subjective  symptoms  in  ectopic  preg- 
nancy until  there  is  rupture  of  the  surrounding  envelope.  The  patient  usually 
passes  her  regular  time  of  menstruation  and  often  considers  herself  pregnant. 
In  the  typical  case  the  first  symptom  is  a  sharp  lancinating  pain  in  the  side, 


Fig.  207. — Decidua  in  Tube. 
Low  power.     In  the  upper  right  part  of  the  drawing  can  be  seen  the  swollen  stroma  cells  of  a. 
villus  of  the  tube  which  have  taken  on  the  characteristics  of  decidua  cells.     In  the  upper  left  is  a 
chorionic  vUlus.     In  the  lower  right  is  a  blood-vessel.     Blood-corpuscles  are  seen  lying  in  the  tis- 
sue.    (From  a  case  of  tubal  pregnancy.) 


which  may  be  so  severe  as  to  cause  the  patient  to  fall.  Pallor,  small  rapid  pulse, 
and  air-hunger  follow,  and,  if  the  rupture  is  through  the  outer  capsule  into  the 
abdominal  cavity,  or  if  there  is  abundant  hemorrhage  from  the  ostium  of  the 
tube,  the  patient  may  bleed  to  death  in  a  short  time.  Catastrophies  of  this  kind 
are,  however,  comparatively  uncommon.  In  the  majority  of  cases  the  patient 
survives  the  first  attack,  which  may  be  so  mild  as  to  cause  little  apprehension. 
Patients  often  describe  the  attack  afterward  as  a  fainting  spell.  If  the  first 
hemorrhage  is  survived  the  patient  continues  to  have  repeated  twinges  of  pain,. 


SPECIAL   GYNECOLOGIC   DISEASES 


511 


usually  of  a  sharp,  lancinating  character.  Very  soon  after  the  first  symptom  of 
pain  the  uterine  bleeding  appears.  This  is  rarely  profuse.  In  the  course  of 
time  shreds  of  decidua  are  discharged,  described  by  the  patient  as  fleshy  mate- 
rial, while  sometimes  the  decidua  is  expehed  entire  in  the  form  of  a  cast  of  the 
uterine  canal.  When  the  symptoms  pursue  this  course,  the  case  is  to  be  regarded 
as  one  of  tubal  abortion,  in  which  the  initial  active  hemorrhage  was  sufficiently 
delayed  by  the  pressure  of  the  tubal  capsule  to  cause  clotting.     Examination 


•  -    ,.,./.  \°_     'a  "  '0-.    '.'.      "      b   ■.   o      »ol   e       0-  0*'°."'     '''»     "  '  0  >°   -X 


Fig.  208, — Decidual  Cast. 
Low  power.  The  stroma  cells  of  the  endometrium  become  enlarged,  most  of  the  enlargement 
being  in  the  protoplasmic  part  of  the  cell,  and  they  become  flattened  instead  of  round  and  oval,  due 
to  pressure  against  each  other.  The  intercellular  connective  tissue  disappears.  The  epithelium  of 
the  glands  is  lost  or  consists  of  a  single  layer  of  low  inactive  cells.  There  is  a  slight  infiltration  with 
leukocytes.     Decidual  casts  are  found  in  extra-uterine  pregnancy. 

of  a  patient  with  tubal  abortion  discloses  a  pelvic  mass.  If  the  bleeding  is  con- 
fined to  the  tube  it  can  at  first  be  felt  as  a  sausage-shaped  tumor,  extending  at 
right  angles  to  the  uterus.  If  the  tubal  mole  becomes  large  and  heavy  it  sinks 
into  the  posterior  culdesac,  where  it  can  be  felt  as  a  rounded,  well-defined  mass, 
pushing  the  uterus  forward  toward  the  pubes.  If  there  is  gradual  bleeding  into 
the  peritoneal  cavity  a  hematocele  forms,  usually  in  the  posterior  culdesac,  which 
at  first  is  felt  per  vaginam  as  a  soft  doughy  mass,  and  if  successive  examinations 
are  made  its  increase  in  size  may  be  recognized. 


512  GYNECOLOGY 

If  the  hematocele  remains  for  a  long  time  in  the  cavity  without  absorption 
a  semi-organized  capsule  forms  about  it,  which  gives  the  examining  finger  the 
sensation  of  a  cyst  or  soft  myoma.  The  hematocele  may  become  so  large  as  to 
be  easily  felt  through  the  abdomen,  sometimes  extending  to  the  level  of  the 
umbilicus. 

Tubal  abortions,  even  when  the  hematocele  is  of  large  size,  sometimes  heal 
spontaneously  by  absorption  of  the  blood-clot.  This  process  is  occasionally 
astonishingly  rapid.  More  often  the  symptoms  continue  for  several  weeks 
until  surgical  aid  is  sought.  During  this  period  the  patient  continues  to  have 
frequent  pain  and  irregular  uterine  bleeding.  The  protein  decomposition  of  the 
clotted  blood  often,  though  not  always,  produces  a  form  of  auto-intoxication, 
which  may  be  of  a  serious  character.  Patients  with  absorbing  heinatoceles  are 
apt  to  run  a  moderate  elevation  of  temperature  and  suffer  from  various  intes- 
tinal disturbances.  Sometimes  they  acquire  a  peculiar  greenish,  waxy  pallor 
of  the  facies  and  occasionally  exhibit  mental  aberrations.  A  moderate  leuko- 
cytosis is  usually  present. 

If  the  hematocele  becomes  infected,  symptoms  of  acute  pelvic  inflammatory 
disease  ensue,  usually  of  a  very  serious  nature. 

Diagnosis. — One  seldom  sees  an  extra-uterine  pregnancy  in  the  first  stage 
before  rupture.  In  this  stage  the  tube  is  soft  and  not  easily  palpable.  The 
delay  of  menses  and  the  enlargement  of  the  uterus  make  an  exact  differentia- 
tion from  a  normal  pregnancy  very  difficult. 

In  the  second  stage,  or  that  of  rupture,  the  cases  of  severe  bleeding  are  very 
characteristic  and  easily  recognizable.  The  sudden  terrific  abdominal  pain 
and  the  tragic  collapse  of  a  woman  in  full  health  is  unmistakable. 

In  the  chronic  stage  the  diagnosis  is  often  confused  and  difficult  to  make. 
The  history  is  of  the  greatest  importance,  the  chief  factors  of  which  are  the  age 
and  social  condition  of  the  patient,  the  question  of  delayed  menses,  the  charac- 
ter and  location  of  the  initial  and  succeeding  pains,  and  the  time  and  nature  of 
uterine  bleeding. 

Most  patients  with  ectopic  pregnancy  give  a  history  of  passed  or  delayed 
menses,  but  occasionally  cases  are  seen  in  which  there  has  been  no  appreciable 
irregularity,  and  when  this  happens  the  diagnosis  is  especially  misleading.  The 
nature  of  the  pain  in  ectopic  cases  is  usually  rather  characteristic.  It  is  felt 
in  one  side  of  the  pelvis,  and  is  peculiarly  sharp  and  lancinating  and  often 
accompanied  by  fainting  spells.  In  contradistinction  to  this  the  pain  of  an 
abortion  is  less  sharp  and  usually  referred  to  the  uterine  region,  while  the  pain 
of  pelvic  inflammation  is  dull  and  more  constant.  It  is  often  very  hard  to  dis- 
tinguish between  a  tubal  abortion  and  a  threatened  or  incompleted  uterine 
abortion.  In  both  cases  history  of  delayed  menses,  pain,  and  onset  of 
bleeding  correspond  to  either  condition.  The  pelvic  examination  may  also 
be  equivocal,  for  the  uterus  is  enlarged  and  soft  in  both  conditions,  while  a 
large  corpus  luteum  or  cystic  ovary  of  a  normal  pregnancy  may  present  to 


SPECIAL   GYNECOLOGIC   DISEASES  513 

the  examining  finger  a  feeling  no  different  from  that  of  a  small  tubal  sac  of  an 
ectopic  pregnancy. 

Microscopic  examination  of  curetings  give  some  information,  for  if  chori- 
onic villi  are  present  ectopic  may  be  ruled  out.  Sometimes,  however,  the  fetal 
remains  of  a  uterine  abortion  disappear  rapidly,  while  the  decidual  reaction 
may  be  seen  for  a  considerable  time.  Under  these  conditions  the  microscopic 
examination  would  be  of  no  value. 

An  interstitial  pregnancy  is  essentially  ectopic,  and  its  symptoms  and  course 
are  practically  the  same  as  those  of  tubal  pregnancy.  The  diagnosis  by  bi- 
manual examination  is  very  difficult  and  requires  a  most  expert  touch;  when 
there  is  doubt,  examination  under  ether  should  be  urged. 

Sometimes  a  normal  pregnancy  at  two  or  three  months,  in  which  there  is 
some  asymmetry  of  the  uterus,  may  simulate  closely  an  extra-uterine  pregnancy 
at  first  examination.     Under  anesthesia  the  doubt  is  usually  expelled  at  once. 

On  account  of  the  ease  by  which  errors  can  be  made  in  the  diagnosis  be- 
tween extra-uterine  and  normal  pregnancy  it  is  important  always  to  make  a 
preliminary  vaginal  examination  under  ether  before  performing  an  abdominal 
operation  for  ectopic  pregnancy.  If  this  is  made  a  routine  procedure,  unneces- 
sary surgery  will  not  infrequently  be  avoided. 

The  expulsion  of  decidual  shreds  or  a  uterine  cast  is  very  useful  evidence  in 
cases  of  suspected  ectopic  pregnancy,  but  even  this  may  be  misleading,  especially 
in  women  who  have  a  history  of  exfoliative  dysmenorrhea. 

The  doughy,  irregular  feel  of  a  soft  pelvic  hematocele  is  quite  recognizable, 
especially  if  the  uterus  can  be  well  defined  as  being  pressed  forward  in  ante- 
position.  If  the  hematocele  acquires  a  semi-organized  capsule  the  mass  becomes 
smoother  and  firmer  to  the  touch  and  may  be  quite  deceptive.  Such  a  tumor 
may  simulate  closely  an  ovarian  cyst,  a  soft  myoma,  or  a  pus-tube.  It  may,  if 
symmetrically  placed  in  the  posterior  culdesac,  feel  exactly  like  a  retroflexed 
fundus  of  a  pregnant  uterus. 

The  differential  diagnosis  between  a  long-standing  tubal  abortion  and  pelvic 
inflammation  is  sometimes  very  baffling. 

The  tubal  mass,  the  intermitting  pain,  and  the  irregularity  of  the  menses  maj^ 
sometimes  apply  to  either  condition,  and  a  mistaken  diagnosis  is  often  made. 
Little  harm  is  done,  however,  by  the  mistake,  as  an  operation  is  usually  indi- 
cated in  both  cases. 

As  a  rule,  extra-uterine  pregnancy  is  unaccompanied  by  temperature,  but  if 
there  is  a  disintegrating  hematocele  a  moderate  fever  may  be  present.  Marked 
elevation  of  temperature  would  indicate  an  inflammatory  process. 

Treatment. — If  an  ectopic  pregnancy  is  discovered  in  the  first  stage — i  e., 
before  rupture- — immediate  removal  of  the  tube  is  indicated. 

In  case  of  tubal  rupture,  with  sudden  collapse  and  alarming  symptoms, 
it  is  undoubtedly  best  to  operate  immediately  if  proper  surgical  facilities  are  at 
hand.     The  operation  can  be  done  very  rapidly,  with  little  additional  shock  to 

33 


514  GYNECOLOGY 

the  patient.  From  the  observation  that  patients  often  survive  the  first  attack 
it  was  at  one  time  the  custom  of  many  surgeons  to  wait  for  this  possible  outcome 
before  attempting  operation.  In  hospital  practice,  at  the  present  time,  ex- 
pectant treatment  is  not  to  be  advised,  for  in  this  way  some  patients  will  be 
lost  who  might  have  been  saved  by  prompt  intervention.  The  modern  simpli- 
fied methods  of  blood  transfusion  constitute  a  valuable  hfe-saving  measure  in 
these  cases  when  used  in  connection  with  a  surgical  operation. 

In  the  third  stage  of  tubal  pregnancy,  namely,  that  of  regression  of  the  hema- 
tocele after  tubal  abortion,  surgical  intervention  is  not  as  urgent,  and  time  may 
usually  be  taken  for  establishing  a  correct  diagnosis.  When  a  diagnosis  is  made 
of  probable  aborted  extra-uterine  pregnane}^  the  question  of  operation  or  ex- 
pectant treatment  arises.  It  is  known  that  many  cases  get  entirely  well  spon- 
taneously and  even  have  later  normal  pregnancies.  Is  it  best,  therefore,  to 
keep  the  patient  under  observation  and  wait  for  this  possible  outcome?  Unless 
the  hematocele  is  far  advanced  in  its  process  of  absorption  and  other  signs  point 
to  an  early  spontaneous  cure  the  expectant  treatment  is  not  to  be  advised.  It 
sometimes  happens  that  a  secondary  rupture  occurs  which  may  be  fatal  to  the 
patient,  and  this  may  take  place  at  any  time  during  the  so-called  termination 
period.  This  catastrophe  is  not  very  common,  yet  it  occurs  sufficiently  fre- 
quently to  act  as  a  menace.  It  is  difficult  at  any  one  time  to  tell  whether  the 
oozing  and  accumulation  of  the  hematocele  has  ceased.  Even  if  imminent  danger 
has  passed,  most  patients  with  hematoceles  are  destined  to  weeks  and  months 
of  invalidism  before  a  complete  absorption  of  the  blood  can  be  accomphshed. 
During  this  time  there  is  risk  of  infection,  formation  of  pelvic  adhesions,  and 
the  toxic  effects  of  the  absorbing  blood-clot.  It  is  better  to  operate,  remove 
such  organs  as  are  necessarj^,  and  completely  empty  the  abdominal  cavity  of 
blood. 

It  may  be  said,  therefore,  in  general,  that  ectopic  pregnancy  in  all  three 
stages  is  very  definitely  a  surgical  disease,  and  that  usually  prompt  intervention 
is  indicated. 

The  technic  of  operating  is  a  matter  of  considerable  moment  and  of  some 
difference  of  opinion.  Unquestionably,  the  abdominal  route  is  the  most  ad- 
vantageous in  all  stages  of  the  disease.  Among  other  reasons  for  using  the 
abdominal  route  is  the  importance  of  removing  the  blood  completelj^  from 
the  abdominal  cavity,  a  procedure  that  cannot  be  as  thoroughly  accomplished 
per  vaginam.  It  was  at  one  time  thought  that  the  absorption  of  blood  from  the 
peritoneal  cavity  was  in  some  way  useful  to  the  patient,  and  some  surgeons 
went  so  far  as  to  leave  as  much  blood  as  possible  in  the  abdomen.  The  error 
of  this  has  already  been  pointed  out,  and  it  is  necessary  to  remove  all  the  blood 
possible  unless  the  patient  is  in  such  extreme  condition  that  the  time  and  manip- 
ulation required  for  sponging  out  the  blood  would  be  dangerous  to  life. 

In  operating  for  ectopic  pregnancy  judgment  as  to  what  tissues  to  remove 
is  a  matter  of  moment.     If  only  the  offending  tube  is  removed,  it  must  be 


SPECIAL    GYNECOLOGIC    DISEASES  515 

remembered  that  the  same  process  that  caused  the  abnormal  nidation  of  the 
ovum  may  act  again  in  the  opposite  tube.  The  figures  of  Richard  R.  Smith, 
who  has  collected  valuable  statistics  on  this  subject,  show  that  only  about  33 
per  cent,  have  normal  uterine  pregnancies  later,  while  about  15  per  cent,  have 
a  repeated  ectopic  pregnancy.  The  question,  therefore,  of  preserving  or  remov- 
ing the  other  tube  is  often  an  important  one.  This  must  be  answered,  as  in 
other  questions  of  conservatism  or  radicalism  in  pelvic  surgery,  on  the  ground 
of  the  age  of  the  patient,  her  desire  for  children,  and  sentimental  considerations 
as  to  the  loss  of  genital  organs. 

The  decision  of  removal  or  preservation  of  the  uterus  must  be  based  on  the 
same  grounds  as  those  in  the  treatment  of  pelvic  inflammatory  disease  {q.  v.). 

DYSMENORRHEA 

The  word  dysmenorrhea  is  used  in  two  somewhat  different  senses.  In  one 
sense  it  is  simply  descriptive  of  the  symptom  pain  occurring  at  menstruation; 
in  the  other  it  is  the  name  of  an  actual  disease.  When  it  is  used  to  denote  a 
disease  it  is  best  to  employ  the  term  essential  dysmenorrhea,  suggested  by 
Schaeffer. 

ESSENTIAL  DYSMENORRHEA 

Essential  dysmenorrhea  is  a  disturbance  that  is  characterized  at  the  time  of 
menstruation  by  severe  cramp-like  pains  of  the  lower  abdomen,  from  which  the 
patient  is  entirely  free  during  the  intermenstrual  period.  This  form  of  dysmen- 
orrhea is  very  distinctive,  and  must  not  be  confused  with  the  kind  of  menstrual 
pain  which  represents  an  aggravation  during  the  menstrual  congestion  of  the 
more  or  less  continued  pain  from  various  pelvic  disorders,  like  salpingitis,  pelvic 
inflammation,  appendicitis,  etc.  This  latter  form  of  dysmenorrhea  might  more 
exactly  be  termed  ''secondary"  or  "acquired  dysmenorrhea." 

Essential  dysmenorrhea,  though  one  of  the  commonest  of  gynecologic  dis- 
eases, is  one  about  which  little  is  known. 

Etiology. — A  satisfactory  interpretation  of  the  etiology  of  true  dysmenor- 
rhea has  not  yet  been  made,  but  the  various  theories  are  iiiteresting  and  are  of 
some  practical  value.  The  older  authors  regarded  the  cause  of  dysmenorrhea 
as  due  entirely  to  mechanical  obstruction.  Others  divided  the  disease  into 
three  classes — an  organic  form,  depending  on  obstruction,  a  congestive,  and  a 
neuralgic  form.  Others  divided  dysmenorrhea  into  uterine  and  ovarian  varie- 
ties. 

The  theory  of  mechanical  obstruction  is  based  on  the  idea  that  the  flow  of 
blood  is  interfered  with  by  a  congenital  stenosis  of  the  internal  os,  so  that,  being 
dammed  back  in  the  uterine  cavity,  it  becomes  clotted  and  acts  as  a  foreign 
body,  setting  up  contractions  of  the  uterine  body.  The  cramp-like  pains  are 
caused  by  the  passage  of  the  clotted  blood  as  it  is  forced  through  the  internal  os. 

This  stenosis  may  be  due  to  a  misplacement,  of  which  anteflexion  is  the  more 


516  GYNECOLOGY 

common  and  retroflexion  the  less  common  tj^pe.  Inasmuch  as  these  two  forms 
of  uterine  flexion  are  due  to  deficient  development,  dysmenorrhea  has  long  been 
regarded  as  the  result  of  genital  hypoplasia. 

In  the  obstructive  theory  the  swelling  of  the  endometrium,  whether  it  be 
the  premenstrual  edema  or  a  true,  permanent,  pathologic  hypertrophy,  plays  a 
considerable  part,  as  it  is  supposed  to  increase  the  obstructive  narrowing  of  the 
internal  os.  Gebhard  describes  an  endometritis  dysmenorrhoica,  in  which  the 
mucosa  is  greatly  thickened  at  the  time  of  menstruation  and  filled  with  fine 
particles  of  clotted  exudate.  He  thinks  that  this  exudate  exerts  a  pressure  on 
the  uterine  nerves  which  is  expressed  by  dysmenorrheic  pain. 

It  should  be  said  in  passing  that  these  views  regarding  endometritis  and 
clotting  of  the  blood  do  not  harmonize  with  the  more  recent  ideas  of  hyper- 
trophic endometrium  as  a  phase  of  a  physiologic  menstrual  cycle,  and  of  the 
clotting  of  the  blood  as  a  result  of  the  abnormal  chemical  influence  of  the  ovarian 
inner  secretion.  Moreover,  the  hypertrophied  endometrium  does  not  seem  to 
be  as  constant  an  accompaniment  of  anteflexion  and  retroflexion  as  the  older 
writers  supposed. 

Theilhaber  denies  that  the  misplacement  of  the  uterus,  or  stenosis  of  the 
internal  os,  or  hypertrophy  of  the  endometrium,  have  anything  to  do  with  dys- 
menorrhea as  etiologic  factors,  but  sees  the  cause  in  a  spastic  contraction  of  the 
circular  muscular  fibers  around  the  internal  os,  called  forth  by  a  predisposition  to 
abnormal  nervous  irritability. 

Menge  refers  the  trouble  to  the  physiologic  menstrual  contraction  waves  of 
the  uterus,  which  in  women  who  are  bodily  and  mentally  sound  are  unnoticed, 
but  which  in  women  who  have  lesions  of  the  genital  organs,  or  who  are  of  a 
neurotic  constitution,  are  felt  as  labor-pains.  In  other  words,  Menge  regards 
the  disease  as  a  psychoneurosis. 

Kronig,  though  admitting  the  possibility  of  mechanical  causes,  considers 
most  dysmenorrheas  as  psj'choneuroses. 

An  interesting  theory'  is  proposed  by  "S^ictor  Schultz,  who  starts  with  the  fact 
that  the  transformation  of  the  infantile  uterus  into  mature  development  is 
gradual  and  often  delayed.  During  this  change  the  connective  tissue  in  the 
outer  laj^er  of  the  uterine  waU,  which  is  in  excess  in  the  infantile  organ,  gives 
way  normally  to  muscle  tissue.  If  this  change  is  delayed  or  does  not  take  place, 
the  uterine  contractions  at  the  menstrual  period  cause  a  "stretching  pain"  in 
the  insufficient  uterine  wall.  This  theory  is  thought  by  Schultz  to  account  for 
the  fact  that  dysmenorrhea  is  so  often  seen  in  persons  with  hypoplastic  genital 
organs.  The  spontaneous  cure  often  seen  after  childbirth  he  considers  as  due  to 
structural  changes  in  the  uterine  wall. 

Stolper  considers  that  dysmenorrheic  pains  are  due  to  uterine  contractions 
in  the  presence  of  congested  circulation.  He  thinks  that  the  real  cause  of  the 
trouble  lies  in  the  abnormal  venous  congestion  of  the  uterus  that  might  result 
from  sexual  or  bodily  overexertion,  constipation,  sedentary  life,  onanism,  etc. 


SPECIAL   GYNECOLOGIC   DISEASES  ^^"^ 

Olshausen  describes  an  ovarian  dysmenorrhea  which  is  independent  of  any 
form  of  pelvic  inflammatory  process,  and  which  he  regards  in  the  light  of  an 

ovarian  neuralgia. 

A  so-called  "nasal  dysmenorrhea"  has  been  described  by  Fhess  and  elaborated 
by  Schaeffer.  It  is  shown  that  in  some  cases  the  pains  of  a  dysmenorrhea  may 
be  cured  by  the  application  of  cocain  to  the  tuberculum  septi,  which  is  desig- 
nated the  "genital  spot." 

With  this  array  of  conflicting  theories,  the  problem  of  etiology  seems  far 
from  a  solution.  Leaving  theory  aside,  there  are  certain  facts  which  occur  with 
sufficient  constancy  to  give  some  basis  for  working  out  a  method  of  treatment. 

There  is  no  question  that  a  malposition  of  the  uterus  occurs  so  frequently 
with  symptoms  of  dysmenorrhea  that  there  m.ust  be  some  etiologic  relation- 
ship between  the  two  conditions.  This  idea  is  substantiated  by  the  fact  that 
many  cases  of  dysmenorrhea  are  completely  cured  by  correcting  the  malposition. 
The  most  common  malposition  seen  in  dysmenorrhea  cases  is  anteflexion, 
while  developmental  retroflexion  is  not  infrequently  met  with.  If  a  large  num- 
ber of  anteflexion  cases  are  studied  it  will  be  found  that  in  the  great  majority 
of  them  the  uterus,  besides  being  anteflexed,  is  retrocessed,  or  sagging  back 
toward  the  sacro-ihac  fossa.  When  the  abdomen  is  opened  and  such  a  uterus 
is  brought  up  toward  the  abdominal  wound,  it  will  be  found  that  the  organ  is 
lax,  and  that  the  angulation  is  due  not  to  an  anterior  spastic  contraction,  but  to 
a  sagging  back  or  a  squatting  down  due  to  relaxation.  The  condition  is,  there- 
fore, actually  one  of  retroposition,  and  differs  only  from  retroversion  in  that  the 
fundus  is  kept  pointing  in  a  forward  direction,  either  by  the  round  ligaments  or 
by  the  structure  of  the  musculature.  The  cervix  in  anteflexion  cases  lies  in  the 
same  position  relative  to  the  vagina  as  it  does  when  the  uterus  is  retroflexed. 
All  plastic  operations  on  the  cervix,  therefore,  do  not  in  any  way  alter  the 
essential  position  of  the  uterus  relative  to  its  normal  level  in  the  pelvis. 

Another  anatomic  condition  frequently  but  not  always  present  in  these 
cases  is  a  distinct  cicatricial  band  at  the  internal  os,  which  can  be  distinctly 
felt  while  dilating  the  cervix,  and  which  often  makes  the  dilatation  of  the  in- 
ternal OS  diflacult.  As  to  the  canal  itself,  an  actual  obstructing  stenosis  is  never 
demonstrable  in  these  cases. 

Hypertrophy  of  the  endometrium  is  by  no  means  constant.  In  our  experience 
it  has  not  appeared  more  frequently  than  in  parous  women  without  dysmenor- 
rhea.    It  is  more  common  in  the  retroflexion  than  in  the  anteflexion  cases. 

Most  of  the  cases  show  a  moderate  degree  of  hypoplasia,  as  indicated  usually 
by  a  long  conical  cervix.  When,  however,  the  uterus  and  adnexa  are  seen  withm 
the  abdomen  and  the  uterus  brought  up  into  position,  the  condition  of  hypoplasia 
often  is  not  noticeable. 

We  find,  therefore,  in  most  cases  of  true  dysmenorrhea  certain  anatomic 
-changes,  which  occur  with  sufficient  regularity  to  assign  a  definite  relationship 
between  them  and  the  menstrual  pain: 


518  GYNECOLOGY 

(1)  Malposition  of  the  uterus  nearly  always  present;  usually  a  retrocession 
with  anteflexion;  less  commonly  a  retroflexion;  occasionally  anteflexion  without 
retrocession. 

(2)  Moderate  hypoplasia,  chiefly  apparent  in  the  form  of  the  cervix,  nearly 
always  present. 

(3)  Cicatricial  band  at  the  internal  os,  not  constant. 

(4)  Hypertrophy  of  the  endometrium,  not  constant. 

The  important  factors  are  malposition  and  hypoplasia  of  the  uterus.  We 
have  seen  that  the  malposition  of  the  uterus  is  usually  due  to  a  relaxation  and 
sagging  of  the  uterus  on  itself,  rather  than  to  a  spastic  contraction  of  the  uterine 
muscles.  The  condition  is  frequently  seen  in  conjunction  with  ptosis  of  the  kid- 
ney or  of  the  colon,  so  that  fundamentally  it  would  seem  as  if  the  lesion  were 
due  uo  a  physiologic  deficiency  in  the  supporting  tissues.  The  so-called  "con- 
genital" misplacements  of  the  uterus  probably  occur  at  the  time  of  puberty, 
when  the  organ  takes  on  a  very  rapid  development,  and  it  is  conceivable  that  a 
■uterus  which  develops  in  an  improper  position  may  be  retarded  in  its  full  growth 
by  partial  interference  with  its  blood-supply.  This  would  account  for  the 
moderate  hypoplasia  that  is  usually  present,  and,  in  this  sense,  the  hypoplasia 
might  be  regarded  as  secondary  to  malposition  of  the  organ.  This  would  also 
explain  the  fact  that  the  condition  is  frequently  seen  in  women  who  are  in  every 
other  respect  fully  developed. 

We  have  shown  in  the  enumeration  of  the  various  theories  as  to  the  etiology 
of  dysmenorrhea  that  by  some  the  symptoms  are  regarded  purely  as  a  mani- 
festation of  a  psychoneurosis.  It  must  be  admitted  that  these  patients  are 
usually  very  nervous  and  often  extremely  neurotic.  The  question  is  raised, 
therefore,  Which  is  primary,  the  dysmenorrhea  or  the  neurotic  condition?  Vede- 
ler,  Kronig,  and  others  believe  the  neurosis  to  be  primary.  We  have  here  the 
same  problem  that  is  discussed  under  the  title  of  Postoperative  Psychoneuroses, 
in  which  it  is  attempted  to  show  that  the  nervous  condition  is  secondary  and 
due  to  constant  nagging  pain  and  discomfort.  In  dysmenorrhea  the  pain  is 
periodic,  to  be  sure,  and  is  completely  absent  during  the  intervening  period. 
Nevertheless,  the  pain  is  so  severe  that  in  time  patients  become  nervously  ex- 
hausted during  the  menstruum.  The  effect  of  this  lasts  longer  and  longer  into 
the  intermenstrual  period,  until  there  comes  a  time  when  the  patient  hardly 
recovers  from  one  period  before  the  next  one  is  upon  her,  and  in  this  way  the 
nervous  irritant  is  constantly  maintained.  The  pathologic  mental  habit  then 
becomes  fixed  and  the  patient  develops  into  a  confirmed  neurotic.  This  course  of 
symptoms  may  frequently  be  followed  in  the  history  given  by  mothers  of  school 
girls  who  are  brought  for  consultation,  in  many  of  whom  the  increase  of  nervous 
symptoms  is  the  chief  cause  for  seeking  medical  advice.  There  is  no  doubt 
that  when  this  condition  of  pathologic  mental  habit  is  reached  there  is  much 
"overvaluation"  and  exaggeration  of  symptoms,  and  that  such  patients  may  be 
greatly  relieved  by  suggestion  and  mental  therapy. 


SPECIAL    GYNECOLOGIC    DISEASES  519 

Symptoms. — The  patient  with  essential  dj^snienorrhea  usually  feels  per- 
fectly well  between  her  periods,  as  far  as  any  local  condition  is  concerned. 
At  the  menstrual  period,  however,  either  just  before  or  at  the  time  of  the  appear- 
ance of  blood,  the  patient  is  seized  with  severe,  often  agonizing,  cramp-hke 
pains  in  the  lower  abdomen,  which  extend  into  the  back  or  down  the  legs,  last- 
ing with  a  few  intermissions  from  a  few  hours  to  one  or  two  daj^s.  During  this 
time  the  patient  is  more  or  less  incapacitated  from  normal  activities  and  is 
usuall}^  confined  to  bed.  Severe  headache  and  general  malaise  are  -often  pres- 
ent, while  vomiting  is  not  uncommon.  The  disease  usually  appears  early  in 
menstrual  hfe,  often  at  the  first  menstrual  period,  and  gradually  increases  in 
severit}'.  It  is  frequenth^  relieved  by  married  hfe,  but  is  sometimes  aggra- 
vated by  it.  Patients  with  essential  dysmenorrhea  are  ver^^  apt  to  be  sterile, 
the  two  conditions  evidently  being  referable  to  the  same  causal  factor.  If, 
however,  pregnancy  and  childbirth  take  place  the  ctysmenorrhea  is  often  cured. 

The  treatment  of  dj'smenorrhea  is  difficult  and  unsatisfactor3^  The  methods 
of  treatment,  both  medical  and  surgical,  are  exceedingly  numerous.  All  the 
methods  used  are  sometimes  successful,  but  all  of  them  fail  frequently.  Medical 
treatment  is  less  satisfactory  than  surgical.  Some  of  the  drugs  used  are  hy- 
drastis,  cottonroot,  viburnum,  aspirin,  antipjTin,  acetanilid  compounds,  hj^- 
oscyamus,  dionin,  salipyrin,  salcodein.  bromids,  ovarian  extract,^  atropin, 
morphin,  cocain,  alcohol,  and  many  others. 

.\mong  the  nmnerous  drugs  used  for  dysmenorrhea,  atropin  is  at  present  receiving  much 
attention.  It  has  been  emploj'ed  with  much  success  by  Drenkhaber,  who  injects  the  drug 
directly  into  the  cervical  canal.  The  dose  is  1  mg.  in  1  c.cm.  of  water.  Many  writers  report 
good  results  by  oral  administration.  The  drug  is  administered  two  days  before  menstruation 
is  expected  to  appear  and  continued  until  the  second  or  third  day  of  menstruation,  depending 
on  the  duration  of  pain.  The  average  dose  is  t^o  grain  three  times  daily.  E.  Novak  recom- 
mends gi\ang  aspirin  in  combination  -n-ith  the  atropin  in  some  cases. 

In  cases  in  which  atropin  does  not  prove  effective  Spitzig  recommends  the  use  of  sodimn 
citrate,  20  grains  three  times  a  day,  during  the  week  or  two  preceding  the  expected  period.  The 
administration  of  citric  salts  is  supposed  to  diminish  the  viscidity  of  the  uterine  blood  that  is 
produced  by  the  menstrual  congestion. 

Klein  divides  dysmenorrhea  into  two  tj'pes,  one  in  which  there  is  h\'peractivity  of  the 
ovarian  secretions  and  one  in  which  the  fimctioh  is  defective.  In  the  first  case  there  is  exces- 
sive edema  of  the  uterine  mucosa.  He  regards  the  uterine  coUc  under  these  conditions  as 
caused  by  the  sweUing  of  the  mucous  membrane.  In  the  second  type  of  dj'smenorrhea  there 
is  atrophy  of  the  mucous  membrane  and  a  flabby  undeveloped  musculature  of  the  uterus.  In 
this  tj'pe  Klein  thinks  that  the  uterus  is  unable  to  expel  the  blood  properl}',  so  that  it  stagnates, 
becomes  clotted,  and  thus  causes  pain  when  finally  expelled.  On  the  theory'  that  the  ovarian 
and  adrenal  secretions  are  antagonistic  Klein  recommends  the  use  of  adrenaUn  in  cases  of  dys- 
menorrhea due  to  oversecretion  of  the  ovary  and  reports  only  two  failures  in  the  treatment  of 
35  patients.  In  the  second  tj-pe  of  case  where  the  ovarian  secretion  is  deficient  he  recommends 
gi\dng  pituitrin  -^-ith  the  adrenalin,  on  the  groimd  that  it  causes  contractions  of  the  uterus  and 
thus  promotes  early  discharge  of  the  blood  before  it  becomes  clotted. 

^  The  author  has  recenth'  had  striking  success  in  a  number  of  dysmenorrhea  cases  ■with  a  prepara- 
tion of  desiccated  ovaries  of  pregnant  animals  minus  the  corpus  luteum.  Thei<most  marked  ejBfect 
of  this  extract  is  seen  in  its  influence  on  the  headache,  nausea,  and  vomiting  from  which  many 
dysmenorrheic  patients  suffer.     See  also  section  on  Ovarian  Organotherapy. 


520  GYNECOLOGY 

The  nasal  treatment  of  dysmenorrhea,  first  suggested  by  FHess  in  1897,  has 
received  considerable  stimulus  of  late  years  from  the  work  of  Brettauer  and 
Mayer,  who  have  reported  numerous  successful  results  in  properly  selected 
cases.  According  to  their  reports,  immediate  relief  is  almost  invariably  ac- 
corded to  those  who  have  abnormalities  of  the  nose,  such  as  deflected  septa, 
hypertrophy  of  the  middle  turbinates,  enchondroses  of  the  septum,  etc.  In 
this  class  also  are  included  those  cases  which,  without  anatomic  stenoses,  exhibit 
tumefaction  and  engorgement  of  the  mucous  membrane  about  the  ''genital 
spots"  at  the  time  of  menstruation.  The  treatment  is  especially  successful  in 
the  type  of  dysmenorrhea  that  is  characterized  by  premenstrual  headache, 
nausea,  and  colic  at  the  onset  of  the  flow. 

Brettauer  and  Mayer  have  given  up  the  use  of  cocain,  as  originally  recom- 
mended by  Fhess,  and  in  their  later  work  have  used  the  galvanocautery  or  tri- 
chloracetic acid,  chiefly  the  latter,  the  results  of  which  they  find  more  lasting 
than  those  after  the  use  of  cocain  alone.  Their  present  technic  is  to  make  four 
apphcations  of  trichloracetic  acid  between  the  periods,  and  if  beneficial  results 
follow,  to  repeat  the  same  treatment  during  the  next  intermenstrual  period. 
By  this  method  they  obtain  permanent  relief  in  from  50  to  75  per  cent,  of 
cases. 

The  operative  and  orthopedic  treatment  of  dysmenorrhea  is  based  on  the 
assumption  that  the  principal  etiologic  factor  is  a  mechanical  one  and  lies  in- the 
improper  anatomic  position  of  the  womb.  The  following  are  some  of  the  opera- 
tive measures  used: 

The  operation  of  dilatation  and  curetment  has  been  used  from  the  time 
of  Marion  Sims, -the  original  idea  being  to  correct  the  stenosis  of  the  internal  os 
and  to  straighten  out  the  angulation  of  the  cervix.  The  curetment  was  for  the 
purpose  of  removing  the  supposedly  inflamed  mucous  membrane,  which  by  its 
swelhng  was  thought  to  aid  in  obstructing  the  uterine  canal.  This  operation 
frequently  effects  relief  and  even  complete  cure  of  dysmenorrhea.  Almost  as 
frequently  it  does  no  good  at  ah.  No  satisfactory  explanation  of  either  the 
positive  or  negative  results  of  this  operation  can  be  given,  but  it  may  be  said 
that  it  is  successful  sufficiently  often  to  warrant  its  routine  use  either  by  itself 
or  in  connection  with  other  more  elaborate  surgical  procedures. 

In  our  own  series  of  cases,  in  which  we  have  been  able  to  obtain  definite  reports  at  least 
a  year  after  the  operation,  60  per  cent,  of  the  dysmenorrhea  patients  were  reheved  or  cured  by 
simple  dilatation  and  curetment.  The  other  40  per  cent,  were  either  not  relieved  at  all  or 
only  temporarily  so. 

A  second  type  of  surgical  treatment  for  anteflexion-dysmenorrhea  is  repre- 
sented by  various  plastic  operations  on  the  cervix  designed  to  straighten  out  the 
canal.  The  most  commonly  used  of  these  operations  is  the  posterior  discission 
of  the  cervix.     The  technic  employed  in  this  country  is  that  of  Dudley,  which  is 


SPECIAL    GYNECOLOGIC    DISEASES  521 

described  on  page  694.  Many  excellent  results  have  been  reported  from  this 
method,  both  as  to  relieving  dysmenorrhea  and  sterility.  The  objection  to  the 
operation  is  that  it  mutilates  the  cervix  and  leaves  a  condition  of  artificial 
laceration  which  sometimes  has  to  be  repaired  in  order  to  relieve  symptoms. 
By  this  operation  the  cervix  is  slit  open  as  far  as  the  internal  os,  so  that  the 
cer"vdcal  canal  is  entirely  eliminated,  and  the  uterine  canal  opens  into  the  vagina 
directly  from  the  internal  os. 

Another  similar  operation  is  that  proposed  bj^  Pozzi  (see  page  693),  which 
consists  of  dividing  the  cervix  bilaterally  up  to  the  internal  os  and  approximat- 
ing the  edges  of  the  wound  in  such  a  way  that  a  permanent,  deep,  bilateral 
artificial  laceration  is  effected.  This  operation  is  open  to  the  same  objection 
as  that  of  Dudley.     It  is  apt  to  be  followed  by  a  troublesome  endocervicitis. 

Still  another  operation  on  the  cer\dx  is  one  used  many  years  ago  by  Pfan- 
nenstiel  and  later  re\'ived  bj^  W.  H.  Baker.  It  consists  in  the  removal  of  a  trans- 
verse wedge  from  the  posterior  hp  of  the  cervix  as  high  up  toward  the  vault  of 
the  vagina  as  possible.  After  se\^dng  up  the  wound  made  by  the  removal  of 
the  wedge,  the  angulation  of  the  cervix  is  straightened  out  and  the  parts  are  left 
in  a  normal  unmutilated  condition.  This  operation  is  sometimes,  but  not  always, 
successful. 

In  operations  of  this  type  the  cervical  canal  is  always  dilated  as  a  routine 
measure. 

The  orthopedic  treatment  of  dj'smenorrhea  in  anteflexion  cases  is  the  use 
of  a  uterine  stem-pessary,  inserted  after  dilatation  and  curetment  under  ether, 
and  left  in  for  two  or  three  menstrual  periods,  according  to  the  method  suggested 
by  Davenport.  This  method  of  treatment  is  often  very  effective.  The  objec- 
tion to  it,  however,  is  that  it  violates  the  laws  of  antisepsis,  and  leaves  in  the 
uterine  canal  a  foreign  bodj'  which  cannot  be  kept  clean. 

A  third  and  more  satisfactory  tj'pe  of  operation  for  dysmenorrhea,  including 
cases  of  both  ante-  and  retroflexion,  is,  in  addition  to  the  dilatation  of  cervix, 
the  performance  of  an  abdominal  operation,  with  a  proper  suspension  of  the 
uterus  so  as  to  straighten  out  the  angulation.  This  method  of  treating  ante- 
flexion is  a  result  of  observations  that  the  uterus  when  anteflexed  is  usually  in 
a  condition  of  relaxation,  being  retrocessed  toward  the  sacrum  and  doubled  on 
itself.  By  drawing  the  uterus  forward  and  facing  it  sHghth^  toward  the  ab- 
dominal wall  the  angulation  of  the  uterus  may  be  completely  reduced.  This 
position  may  be  made  permanent  by  abdominal  shortening  of  the  round  hga- 
ments,  or  by  an  anterior  fbcation,  or  by  Olshausen's  fixation  of  the  round  hga- 
ments.  We  have  by  this  method  been  able  to  secure  satisfactory  results  in 
75  per  cent,  of  cases. 


522  GYNECOLOGY 

MEMBRANOUS  DYSMENORRHEA 

The  appellation  "membranous  dysmenorrhea"  relates  to  a  condition  by  which 
at  each  monthly  period  the  entire  uterine  mucosa  is  exfohated  and  discharged. 
The  process  is  not  well  understood  and,  consequently,  various  names  have 
been  attached  to  it.  It  is  commonly  classified  as  a  form  of  dysnienorrhea  be- 
cause in  most  cases  the  passing  of  the  membrane  is  accompanied  by  severe  cramp- 
like uterine  pain.  In  some  instances,  however,  pain  is  not  present,  so  that 
the  expression  "menstrual  exfohation  of  the  uterine  mucosa"  is  preferred  by 
some.  Owing  to  the  fact  that  the  extruded  membrane  often  shows  evidences 
of  inflammation,  others  name  the  condition  "exfoliative  endometritis."  "Mem- 
branous" or  "membranaceous  dysmenorrhea"  is  the  term  most  commonly  used. 

In  a  typical  case  there  is  discharged  each  month  at  the  menstrual  period  a 
bag-like  cas.t  of  the  uterine  canal  which  is  three-cornered  in  form,  with  openings 
at  each  angle,  two  of  them  corresponding  to  the  beginnings  of  the  tubal 
canals  and  the  other  to  the  internal  cervical  orifice.  The  outer  surface  of  the 
sac  is  rough  and  shaggy,  of  a  grayish-red  color,  and  represents  the  submucous 
tissue  where  the  membrane  has  been  torn  from  its  bed.  The  inner  surface  of 
the  sac  is  pale,  velvety  and  undulating,  and  corresponds  to  the  surface  of 
the  uterine  mucous  membrane.  The  thickness  of  the  membranous  wall  is 
1  to  3  mm.  The  entire  membrane  does  not  always  come  away  intact,  but  more 
frequently  becomes  broken,  so  that  it  appears  in  pieces  or  shreds  of  tissue  of 
varying  sizes-.  Careful  inspection  of  these  s-hreds  reveals  the  characteristic 
surfaces,  though  to  casual  observation  they  often  look  like  washed-out  organized 
blood-clots. 

The  microscopic  picture  of  the  dysmenorrheic  membrane  is  not  an  entirely 
constant  one.  The  most  distinctive  feature  is  an  enlargement  of  the  stroma 
cells,  which  gives  an  appearance  very  similar  to  the  decidua  of  uterine  or  ectopic 
pregnancy,  though,  as  a  rule,  the  cell  enlargement  is  less  marked  than  in  the 
case  of  a  true  decidua.  In  addition  to  the  change  in  the.  stroma  cells  the  gland 
elements  are  wider  apart  than  normal,  and  there  is  usually  localized  infiltration 
of  small  round  cells,  with  the  characteristic  changes  of  an  interstitial  endo- 
metritis. The  surface  epithelium,  is  often  desquamated.  The  entire  section 
usually  stains  more  faintly  than  does  normal  uterine  mucosa.  The  microscopic 
appearance,  however,  varies  in  specimens  from  different  individuals,  and  in 
different  specimens  from  the  same  individual,  sometimes  showing  well-marked 
evidence  of  endometritis,  sometimes  exactly  simulating  true  decidua,  and  some- 
times showing  no  variation  at  all  from  a  normal  mucous  membrane. 

It  will  thus  be  seen  that  a  differential  diagnosis  cannot  always  be  made 
by  microscopic  examination  between  membranous  dysmenorrhea,  early  abor- 
tion, and  extra-uterine  pregnancy. 

In  addition  to  the  typical  exfoliated  membrane  above  described,  casts  and 


SPECIAL    GYNECOLOGIC    DISEASES  523 

shreds  of  tissue  are  sometimes  periodically  discharged  which  are  composed 
chiefly  of  fibrin,  with  only  a  scattered  remnant  of  glandular  elements  to  be 
found  in  the  tissue.  Membranes  of  this  kind  are  apt  to  show  considerable  evi- 
dence of  inflammatory  reaction  in  the  form  of  round  cells  and  leukocytes  col- 
lected in  the  meshes  of  fibrin.  To  this  condition  has  been  given  the  name 
^'fibrinous  endometritis." 

The  etiology  of  membranous  dysmenorrhea  is  very  obscure.  In  a  certain 
number  of  cases  the  disease  dates  back  to  an  abortion.  In  a  few  instances  an 
hereditary  element  is  evident.  The  present  tendency  is  to  refer  the  condi- 
tion to  an  abnormal  reaction  between  the  ovarian  secretion  and  the  uterine 
mucosa.  It  has  been  pointed  out  (Halban  and  others)  that  menstruation, 
membranous  dysmenorrhea,  and  decidua  formation  represent  different  degrees 
of  the  same  physiologic  process — i.  e.,  reaction  of  the  uterine  mucosa  to  the 
influence  of  the  ovarian  secretion. 

It  is  possible  that  the  underlying  cause  may  be  ascribed  in  some  cases  to  an 
interstitial  endometritis  which  produces  an  abnormal  desquamation  at  the  men- 
strual flux.  This  is  a  plausible  explanation  for  those  cases  which  date  from  an 
abortion. 

The  chief  symptoms  of  membranous  dysmenorrhea  is  catamenial  pain, 
which  may  be  very  severe  or  be  only  a  dull,  dragging  sensation.  Rarely  pain  is 
entirely  absent. 

Many  patients  are  sterile,  but  sterility  is  not  always  present.  In  one  of 
our  cases  the  patient  had  an  extra-uterine  pregnancy  about  a  year  after  an 
unsuccessful  cureting  for  the  disease. 

The  diagnosis  of  the  affection,  as  has  been  noted,  cannot  always  be  made 
with  the  microscope,  even  by  the  most  expert  microscopist.  For  this  reason 
the  diagnosis  of  any  decidual  membrane  should  never  be  dogmatically  made 
without  taking  into  consideration  the  patient's  menstrual  history. 

The  prognosis  of  membranous  dysmenorrhea,  as  regards  complete  cure,  is 
not  good,  and  the  treatment  is  very  unsatisfactory.  Schaefer  (in  Veit)  reports 
2  successful  cases  in  which  hydrastis  was  used. 

Treatment. — The  usual  recommendation  is  that  of  repeated  curetings  just 
before  the  onset  of  the  menstrual  period.  At  each  curetment  the  uterine  cavity 
is  treated  with  iodin.  In  our  experience  it  has  been  difficult  to  persuade  patients 
to  undergo  the  treatment  a  sufficient  number  of  times  to  test  its  real  efficacy. 

AMENORRHEA  OF  YOUTH 

The  various  pathologic  concUtions  with  which  amenorrhea  is  associated,  or 
of  which  it  is  a  symptom,  are  enumerated  in  the  section  on  General  Symptoma- 
tology. When  amenorrhea  is  one  of  the  manifestations  of  some  organic  disease, 
such  as  tuberculosis,  chlorosis,  etc.,  treatment  is  directed  toward  the  funda- 


524  GYNECOLOGY 

mental  disease.  In  many  cases  amenorrhea  signalizes  hypofunction  of  the 
ovarian  function,  and  may  appear  either  as  an  abnormally  delayed  menarche 
(puberty)  or  as  a  cessation  of  menstruation  that  has  already  been  established. 
An  allied  condition  is  that  of  unnaturally  scanty  menstrual  flow  (oligomenor- 
rhea). In  many  cases  of  youthful  amenorrhea  and  oligomenorrhea,  hypoplasia 
of  the  internal  or  external  genital  organs  can  be  demonstrated.  In  man}^  cases, 
however,  no  anatomic  abnormality  is  discoverable.  Some  of  the  patients  are 
underdeveloped  in  their  general  organism,  and  are  of  the  asthenic,  nervous  type, 
while  others  may  be  well  developed  and  continue  in  perfect  health. 

The  specific  treatment  of  youthful  amenorrhea  consists  in  the  use  of  the 
various  ovarian  or  lutein  extracts.  In  our  experience  we  have  had  marked 
success  with  the  extract  of  the  entire  ovary,  given  in  5-grain  capsules  three  or 
four  times  daily.  The  effect  of  this  treatment  usually  appears  within  three  or 
four  weeks.  Sometimes  menstruation  appears  in  a  few  days  from  the  time  of 
the  first  administration. 

Amenorrhea  and  oligomenorrhea  have  been  treated  successfully  by  the  use  of  the  intra- 
uterine stem-pessary. 

Rieck  has  reported  cures  in  19  out  of  22  cases,  and  recommends  the  treatment  in  all  cases 
in  which  other  methods,  especially  the  administration  of  ovarian  extract,  have  failed. 

Good  results  from  the  treatment  are  seen  in  from  two  weeks  to  two  or  three  months  after 
the  appUcation  of  the  pessary. 

Rieck  keeps  the  pessary  in  the  uterus  for  eight  months  to  a  year,  even  if  good  results  appear 
early. 

The  author  does  not  recommend  this  treatment. 

MENORRHAGIA  OF  YOUTH 

In  this  category  are  included  those  cases  of  excessive  menstruation  in  which 
no  definite  pathologic  cause  is  demonstrable.  The  condition  is  sometimes 
termed  ''functional  menorrhagia."  It  most  commonly  appears  either  at  or 
soon  after  the  menarche,  but  sometimes  it  does  not  become-  evident  until  several 
years  after  the  establishment  ot  the  menses.  The  bleeding  in  these  cases  is  often 
very  severe  and  prolonged,  and  may  seriously  threaten  the  life  and  health  of  the 
patient.  In  time  the  pelvic  organs  become  much  congested  and  the  uterus  may 
become  large  and  flabby,  sometimes  faUing  back  into  the  position  of  retroflexion. 
Secondary  anemia  and  functional  heart  disturbances  are  apt  to  ensue,  and  arfe 
often  regarded  as  the  cause  instead  of  the  effect  of.  the  uterine  bleeding.  Present 
ideas  refer  the  condition  to  abnormal  function  of  the  ovarian  secretion,  which  in 
some  cases  is  undoubtedly  brought  about  by  a  disturbance  in  the  balance  of  the 
other  organs  of  internal  secretions.  Hertogue,  Duffy,  and  others  consider  that 
it  is  the  result  of  deficiency  in  the  activity  of  the  thyroid,  which  when  functionat- 
ing normally  counterbalances  the  effect  of  the  ovarian  secretion. 

The  treatment  of  the  menorrhagia  of  youth  and  puberty  should  always 


SPECIAL    GYNECOLOGIC    DISEASES  525 

at  first  be  conservative.  The  most  promising  form  of  medicatioji  at  the  present 
time  is  that  of  extract  of  the  pituitary  gland.  The  usual  dosage  is  1  c.c,  given 
subcutaneously  every  one  or  two  days  for  an  average  of  ten  doses.  Experience 
seems  to  indicate  that  this  extract  is  decidedly  more  effective  in  the  functional 
menorrhagias  of  youth  than  in  those  of  middle  life  (uterine  insufficiency). 

The  alarming  hemorrhages  of  puberty  may  be  successfully  treated  by  blood 
transfusion,  preferably  from  one  of  the  parents;  or  serum  from  human  or  horse's 
blood  may  be  administered  subcutaneously,  in  closes  of  15  to  30  c.c,  repeated 
several  times.  On  the  theory  that  the  hyperactivity  of  the  ovarian  secretion 
in  these  cases  is  caused  or  stimulated  by  a  deficiency  in  the  thyroid  secretion, 
thjToid  extract  is  recommended  in  conjunction  with  pituitrin  (Duffy).  Calcium 
chloric!,  in  doses  of  80  grains  a  day,  is  recommended. 

Local  treatment  should  be  resorted  to  only  secondarily.  Curetment  seems 
to  be  of  little  value.  In  some  of  our  cases  it  had  no  beneficial  effect  whatever. 
There  is  no  doubt  that  in  nearly  all  cases  the  hemorrhage  may  be  stopped  by  the 
use  of  the  .T-ray.  It  must  be  remembered,  however,  that  the  effects  of  the  a;-ray 
are  accomplished  at  the  sacrifice  of  the  ripening  follicles  of  the  ovaries.  Al- 
though it  is  clamied  that  with  present  improved  methods  the  application  of  the 
rays  may  be  so  tempered  as  to  check  but  not  destroy  the  ovarian  function,  one 
would  hesitate  to  subject  a  young  patient  to  the  treatment  unless  all  other  meth- 
ods fail.  The  treatment  of  youthful  menorrhagia  by  radium  is  discusspd  below 
at  length  in  the  section  on  the  Use  of  Eadium  m  Non-malignant  Conditions. 
With  the  foregoing  measures  available,  a  final  resort  to  surgical  castration 
should  be  a  rare  necessity. 

RADIUM  IN  THE  TREATMENT  OF  NON-MALIGNANT  GYNECOLOGIC 

DISEASES 

Radium  has  become  an  invaluable  resource  to  the  gynecologist  not  only  in 
the  treatment  of  cancer,  but  in  certain  non-malignant  conditions,  chief  of  which 
are  the  menorrhagias  and  metrorrhagias  of  uncertain  pathologic  origin.  In 
this  field  of  therapy  radium  has  attained  its  surest  position  of  usefulness,  for 
whereas  in  the  treatment  of  cancer  its  ultimate  value  is  still  problematic,  in 
metropathic  hemorrhages  it  may  be  regarded  almost  as  an  unfailing  specific. 
So  important  and  satisfactory  in  its  results  has  radium  become  in  this  class  of 
cases  that  its  discovery  may  perhaps  be  regarded  as  marking  the  greatest  single 
advance  that  has  occurred  for  many  years  in  gynecologic  science.  Patients  who 
formerly  passed  through  long  periods  of  continuous  or  recurrent  bleeding,  re- 
lieved imperfectly  or  not  at  all  by  repeated  surgical  or  medical  treatment,  many 
of  them  coming  eventually  to  hysterectomy,  may  now  often  be  completely  cured 
by  a  single  application  of  radium. 

Up  to  the  present  time  the  exact  manner  in  which  radium  acts  to  control  the 


526  •  GYNECOLOGY 

bleeding  of  a  metropathic  uterus  has  not  been  conclusively  determiiied.  There 
is  no  doubt  that  a  sufficient  dosage  maj^  destroy  the  primordial  and  ripening 
folHcles  of  the  ovary  and  in  this  way  prevent  the  cause  of  hemorrhage  at  its  main 
source.  The  readiness,  however,  with  which  even  moderate  doses  of  radium  will 
check  bleeding  and  regulate  the  menses  to  normal  rhythm  and  duration  makes 
it  probable  that  some  beneficial  influence  is  exerted  on  the  endometrium  itself. 
This  problem  has  not  yet  been  worked  out,  for  the  time  during  which  radium  has 
been  employed  for  this  purpose  has,been  so  short  and  the  opportunities  for  histo- 
logic examination  so  limited  that  no  searching  investigations  have  been  carried 
out.  Clark,  in  a  recent  paper,  reported  a  case  in  which  hj-sterectomy  had  been 
performed  shortly  after  an  'intra-uterine  apphcation  of  radium.  A  careful 
microscopic  examination  of  the  tissues  of  uterus  and  ovaries  failed  to  reveal  any 
distinctive  change  that  might  be  attributable  to  the  influence  of  radiation. 
That  there  is  some  tissue  like  the  endometrium  outside  of  the  ovaries  which  is 
perhaps  the  principal  factor  in  this  form  of  treatment  is  suggested  b}^  the  fact 
that  in  some  instances  the  ordinary  dosage  of  radium  is  insufficient  to  check  the 
hemorrhage  and  that  enough  radium  must  be  applied  to  destroy  the  ovarian  fol- 
licles and  cause  atrophy  of  the  ovaries  (Wood). 

Selection  of  Cases.^ — Uterine  Insufficiency .^The  treatment  of  radium  for 
metropathic  bleeding  may  be  extended  to  a  wide  range  of  cases.  The  most 
important  of  these  repi'esent  the  condition  which  we  have  described  as  uterine 
insufficiency.  The  majority  are  patients  approaching  the  menopause,  though 
many  are  younger.  Then  symptom  is  menorrhagia  in  its  various  forms.  JNIanj^ 
have  metrorrhagia,  sometmies  lasting  almost  continuously  for  months.  With 
the  exception  of  a  greater  or  less  degree  of  secondary  anemia  they  exhibit  no 
special  local  or  constitutional  changes.  As  we  have  seen  in  the  section  on  Uterine 
Insufficiency  the  pathology  of  this  condition  is  not  understood.  Careful  examina- 
tion of  the  endometrium  reveals  no  gross  or  microscopic  lesion  to  account  for  the 
abnormal  bleeding.  Most  of  these  patients  when  they  come  to  the  attention  of 
the  gynecologist  have  been  treated  to  no  avail  with  the  various  drugs  commonly 
prescribed  for  uterine  hemorrhage.  Many  of  them  have  been  subjected  to  one 
or  more  operations  for  curetage.  Without  the  help  of  radium  the  usual  course 
of  treatment  is  to  repeat  to  a  certain  extent  the  measures  that  have  already  been 
used,  including  a  final  curetage.  As  the  bleeding  usually  continues,  a  hysterec- 
tomy is  reluctantly  advised  and  submitted  to.  In  patients  of  this  type  radium 
produces  its  most  satisfactory  results,  -one  treatment  usually  sufficing  to  efi^ect  a 
permanent  cure.  The  amount  of  dosage  depends  on  the  question  whether  or  not 
it  is  desirable  to  estabhsh  a  premature  menopause.  If  the  patient  is  at  the  climac- 
teric age  it  is  often  advisable  to  bring  about  complete  amenorrhea,  and  this  may 
be  accompHshed  by  simply  lengthening  the  time  of  exposure.  If  the  patient  has 
before  her  several  years  of  menstrual  hfe  it  is  usually  best  to  give  such  dosage  as- 
will  check  but  not  completely  arrest  menstruation. 


SPECIAL    GYNJECOLOGIC    DISEASES  527 

A  second  type  of  menorrhagic  cases,,  suitable  for  radium  treatment,  comprises 
those  patients  in  whom  the  hemorrhages  are  the  result  of  a  demonstrable  non- 
mahgnant  disease  of  the  endometrium. 

These  cases  we  do  not  classify  under  the  heading  of  uterine  insufficiency,  a 
term  which  is  applicable  only  where  microscopic  examination  of  the  endometrium 
shows  no  abnormal  changes.  The  non-malignant  diseases  of  the  endometrimn 
that  produce  or  are  associated  with  bleeding  are,  for  the  most  part,  represented 
by  two  types,  namety,  that  which  is  characterized  by  some  form  or  degree  of 
permanent  gland  hypertrophy  and  that  in  which  there  is  an  interstitial  tliickening 
of  the  endometrial  stroma.  These  two  types  must  be  considered  separately  in 
their  relation  to  radium  treatment. 

Gland  Hypertrophy. — Cases  of  permanent  gland  hypertrophy  are  not  easily 
distinguishable  from  those  of  uterine  insufficiency,  for  chnically  the  symptoms  are 
practically  the  same,  and  in  many  instances  there  are  no  palpable  signs  which 
may  lead  to  a  differential  diagnosis.  In  the  more  marked  forms  the  uterus  is 
enlarged  and  boggy,  often  in  some  degree  of  retroposition.  In  these  cases  the 
endometrium  may  be  greatty  thickened  even  to  the  extent  of  half  an  inch  or 
more  and  hangs  down  in  irregular  folds  or  polj'poid  projections.  It  is  frequently 
associated  with  multiple  polyps  of  the  endocervix,  the  observation  of  which  may 
often  suggest  the  diagnosis  of  the  condition  of  the  endometrium. 

Permanent  gland  hypertrophy  may  occur  at  any  period  of  menstrual  life 
from  adolescence  to  the  menopause,  but  it  is  more  common  after  the  age  of  thirty- 
five.  Its  obscure  etiology  is  discussed  elsewhere  (see  Gland  Hj^pertrophy) . 
Patients  with  uterine  bleeding  from  gland  hypertrophy  are  all  suitable  subjects 
for  radium  treatment  with  the  exception  of  the  rare  cases  in  which  the  hyper- 
trophic endometrium  has  reached  the  adenomatous  stage  or  where  great  cystic 
degeneration  has  taken  place.  It  is,  therefore,  not  necessary  to  have  made  a 
previous  differential  diagnosis  between  the  condition  and  that  of  uterine  insuf- 
ficiency. The  existence  of  a  diseased  endometrium  is  usually  first  discovered 
during  the  preliminar}"  cureting  which  should  always  for  purposes  of  exploration 
precede  an  intra-uterine  application  of  radium.  The  difference  between  an 
abnormally  hypertrophied  mucous  membrane  and  certain  phases  of  the  normal 
endometrial  cycle  can  be  learned  only  by  experience.  When  a  tliickened  polypoid 
mucosa  is  found  it  is  of  very  great  importance  to  distinguish  it  from  cancer  of  the 
uterine  body.  As  a  rule  the  diagnosis  is  readily  made  from  gross  inspection  of  the 
tissue.  In  gland  hypertrophj^  the  mucosa  is  removed  by  the  curet  in  long  sohd 
strips  or  in  smooth  polypoid  masses,  with  comparatively  little  bleeding.  If  cancer 
is  present  the  tissue  appears  in  friable  pieces,  with  bleeding  usualty  more  marked. 
If  the  case  is  one  of  polypoid  hypertrophy  it  is  advisable  to  make  a  thorough 
cureting  of  the  uterine  cavity  before  inserting  the  radium,  for  in  this  way  not  only 
is  the  treatment  likely  to  be  more  efficacious,  but  it  helps  to  avoid  the  leukorrheal 
discharge  and  passage  of  shreds  which  otherwise  may  ensue. ,   If  the  mucosa  is 


528  GYNECOLOGY 

apparently  normal  the  curetage  need  not  be  more  than  to  secure  enough  tissue 
for  examination.  If  there  is  doubt  as  to  the  diagnosis  between  hypertrophy 
and  cancer,  the  cureted  tissue  should  receive  immediate  microscopic  examina- 
tion. If  it  proves  to  be  cancer  the  radium  should  be  removed  as  soon  as  the  fact 
becomes  known. 

If  during  the  cureting  the  tissue  removed  is  obviously  cancer  the  curetage 
should  not  be  carried  further  than  is  necessary  to  secure  an  abundance  of  material 
for  microscopic  examination,  and  radium  should  not  be  used,  for  neither  the 
curetage  nor  the  radium  are  of  benefit  for  the  radical  operation  that  is-  now  indi- 
cated. The  reasons  for  not  treating  cancer  of  the  uterine  body  are  given  in  the 
section  devoted  to  that  subject  {q.  v.). 

Interstitial  Endometritis. — A  thickened  mucosa  due  to  interstitial  hyper- 
trophy and  lymphatic  infiltration  of  the  endometrial  stroma  cannot  be  dis- 
tinguished by  gross  inspection  from  permanent  gland  hypertrophy  or  even  from 
the  hypertrophic  phase  of  the  normal  mucous  membrane.  We  have  on  a  few 
occasions  applied  the  radium  treatment  without  harm  in  cases  where  the  cu- 
reted tissue  has  in  the  later  microscopic  examination  revealed  an  interstitial  endo- 
metritis. The  inability  to  detect  by  sight  a  chronic  or  even  an  active  inflamma- 
tion of  the  mucosa  constitutes  a  point  of  weakness  in  the  radium  treatment  of 
metropathic  hemorrhages.  If  the  inflammatory  process  is  confined  to  the  endo- 
metrium it  is  probable  that  no  injury  will  result  from  the  action  of  the  radium. 
Inflammatory  conditions  of  the  mucosa  are,  however,  apt  to  be  associated  with 
latent  inflammations  of  the  pelvis,  which  may  not  be  detected  by  bimanual 
examination,  and  which,  as  we  shall  see,  are  susceptible  of  being  hghted  into 
activity  under  the  influence  of  radiation. 

Menorrhagia  of  the  Young. — In  treating  the  menorrhagias  of  youth  radium 
has  proved  exceptionally  valuable.  Operators  hesitated  at  first  to  employ  ra- 
dium in  these  cases  on  account  of  the  danger  of  establishing  permanent  amenor- 
rhea and  sterility.  This  difficulty  has  now,  for  the  most  part,  been  obviated 
by  an  improved  knowledge  in  the  technic  of  application,  so  that  it  is  possible 
by  proper  dosage  to  regulate  abnormal  menstrual  activity  with  surprising 
precision. 

The  etiology  of  menorrhagias  of  youth  is  as  obscure  as  of  those  occurring  in 
middle  life.  It  is  quite  probable  that  much  the  same  factors  determine  their 
causation.  In  some  no  demonstrable  pathology  can  be  found  and  the  condition 
simulates  closely  that  to  which  the  term  "uterine  insufficiency"  has  been  applied. 
Others  exhibit  a  pronounced  endometrial  hypertrophy  which  is  pecuharly  persist- 
ent and  prone  to  rapid  recurrence  after  curetage.  In  a  few  cases  of  girls  under 
the  age  of  twenty  we  have  found  the  Wassermann  reaction  positive.  Youthful 
masturbation  is  undoubtedly  a  predisposing  factor  in  some.  Whatever  the 
underlying  cause,  the  metropathic  hemorrhages  of  the  young  have  been  particu- 
larly baffling  to  the  gynecologist,  for  not  only  are  drugs  and  the  usual  curetage, 


SPECIAL    GYNECOLOGIC    DISEASES  529 

for  the  most  part,  ineffectual,  but  the  final  resource  of  hysterectomy  or  castration 
is  a  much  more  lamentable  outcome  than  in  older  women. 

So  far  as  present  observations  have  gone  it  seems  entirely  feasible  to  treat 
young  patients  with  modified  doses  of  radium.  So  little  work  in  this  field  has 
been  done  that  there  is  no  standardized  dosage.  It  is  miportant  to  be  extremely 
conservative  and  in  general  to  observe  the  principle  that  the  younger  the  patient, 
the  smaller  should  be  the  dosage,  notwithstanding  the  dictum  of  some  of  the  more 
experienced  operators  that  in  younger  women  uterine  hemorrhage  is  more  resist- 
ant to  radium  than  in  the  more  mature.  On  account  of  the  danger  of  producing 
permanent  amenorrhea  it  is  better  to  give  a  small  dosage  even  if  it  is  necessary  to 
repeat  the  treatment.  A  number  of  our  cases  have  been  young  married  women 
who,  in  addition  to  uterine  bleeding,  have  complained  of  sterility.  In  a  case  of 
this  kind  the  utmost  conservatism  must  be  used,  for  the  production  of  amenorrhea 
in  such  a  patient  would  be  a  disaster  for  which  the  operator  would  hardty  be 
forgiven.  Whenever  radium  is  used  to  regulate  menstruation  even  with  small 
doses  a  temporary  amenorrhea  or  oligomenorrhea  may  appear  sometimes  after 
the  second  or  third  month  following  treatment,  and  of  this  the  patient  should 
previously  be  warned.  In  the  treatment  of  the  menorrhagias  of  pubescence  or 
early  adolescence,  that  is  to  say,  in  girls  of  fourteen  to  sixteen  years  of  age,  we 
have  had  no  experience  with  radium  nor  are  we  able  to  quote  the  work  of  others. 
Young  patients  of  this  class  usually  recover  with  expectant  treatment.  We 
have,  however,  in  the  past  observed  intractable  cases  which  we  should  now 
unhesitatingly  treat  with  radium  after  the  failure  of  the  ordinarj-  medical  and 
hygienic  measures. 

Menorrhagia  of  Fibroids. — The  treatment  of  bleeding  fibroids  with  radium  is 
a  subject  concerning  which  there  is  at  present  much  discussion.  The  use  of  the 
a'-ray  for  fibroids  met  with  comparatively  little  favor  in  this  country,  but  since 
the  advent  of  radium  opinions  regarding  the  influence  of  radiation  on  these 
tumors  has  been  considerably  modified.  This  is  clue  to  the  great  superiority 
which  radium  has  over  the  x-ray  in  treating  uterine  hemorrhages.  The  .-c-ray 
depends  for  its  effects  on  its  destructive  action  on  the  follicles  of  the  ovaries,  in- 
asmuch as  it  cannot  as  readily  be  applied  directly  to  the  uterine  mucosa.  Radimn, 
on  the  other  hand,  although  in  sufficient  dosage  may  create  a  similar  effect  on 
the  ovaries,  undoubtedly  in  small  doses  directty  applied  acts  on  the  endometrium 
entirely  independently  of  the  ovaries.  This  separate  action  is  of  great  impor- 
tance, especially  in  the  treatment  of  fibroids,  for  it  has  been  frequently  demon- 
strated that  the  uterine  is,  in  part  at  least,  independent  of  the  ovarian  function. 
This  has  been  shown  in  the  past  by  the  frequent  failm'e  to  check  mj^omatous 
hemorrhages  b}"  the  obsolete  method  of  castration. 

As  has  been  stated  above,  the  exact  nature  of  the  action  of  radium  on  the  endometrium  is 
not  yet  known.  Abbe  considers  it  the  result  of  secondary  beta  rays,  which  he  claims  "exert  a 
powerful  inhibitive  action  on  new  tissue  and  particularly  on  its  blood-vessels."  According  to 
this  theory  radium  acts  on  the  endothelial  cells  of  the  capillaries,  probably  leading  to  their 
obliteration  (Ransohoff). 
34 


530  GYNECOLOGY 

The  influence  of  radium  on  myomatous  hemorrhage  is  prompt  and  sure,  and 
for  this  reason  the  treatment  is  becoming  more  and  more  popular.  Some  are  so 
enthusiastic  as  to  believe  that  radiimi  should  in  most  cases  supplant  operation. 
Most  operators  are,  however,  more  conservative  and  employ  it  only  in  selected 
cases.  Radium  has  the  power  of  producing  a  greater  or  less  amount  of  shrink- 
age in  myomas  to  which  it  has  been  exposed.  How  far  this  action  may  be  rehed 
upon  in  a  given  case  has  not  j-et  been  accurate^  determined.  Some  claim  that 
it  is  practically  constant. 

Many  of  the  dangers  entailed  in  the  x-ray  treatment  of  fibroids,  such  as 
degenerations,  necroses,  adventitious  burns,  etc.,  are,  for  the  most  part,  negligible 
in  using  radium. 

With  these  advantages  in  its  favor  radium  may  be  regarded  as  comparatively 
safe.  It  is,  therefore,  a  valuable  asset  in  the  treatment  of  such  cases  of  myoma 
which  cannot  be  operated  on  on  account  of  the  patient's  physical  condition, 
and  in  cases  of  small  fibroids  which  are  producing  no  other  symptoms  than 
bleeding. 

At  the  present  time  most  surgeons  are  conservative  in  its  use.  Our  personal 
views  in  the  matter  may  be  summed  up  as  follows : 

All  large  fibroids,  whether  giving  symptoms  or  not,  should  be  subjected  to 
surgical  operation  unless  there  is  some  constitutional  contraindication.  If  such 
is  the  case,  large  bleeding  fibroids  may  be  treated  with  radium.  The  application 
of  radium  merely  for  the  purpose  of  reducing  the  size  of  the  growth  is  not  recom- 
mended except  where  surgery  is  completely  out  of  the  question  and  the  exigen- 
cies of  the  case  require  that  something  be  done. 

In  bleeding  or  degenerating  fibroids  after  the  menopause  surgery  should 
be  employed  except  in  case  of  stern  contraindications  of  a  constitutional 
nature. 

Fibroids  which  are  producing  pressure  s^miptoms  should  be  operated  on. 
These  comprise  especialty  those  that  are  growing  low  in  the  pehds,  including 
cervical  mj^omas. 

Myomatous  polyps  should  be  removed  by  surgery. 

In  the  case  of  comparatively  j'oung  women  with  growing  fibroids,  who  desu'e 
children,  the  operation  of  myomectomy  is  advisable  when  possible.  In  cases  of 
this  kind  radium  is  valuable  to  use  afterward  to  check  the  menorrhagia  which 
sometimes  recurs  even  after  the  myoma  has  been  removed. 

In  cases  of  uterine  hemorrhage  associated  with  small  myomata  radium  treat- 
ment is  alwaj^s  justifiable  and  in  most  cases  advisable. 

When  uterine  myomata  are  complicated  with  a  pelvic  inflammation,  radimn 
is  out  of  the  question. 

Myomata  associated  with  adenocarcinoma  requii'e  surgical  operation. 

Menorrhagia  of  Pelvic  Inflammation. — A  few  cases  have  been  reported  in 
which  after  radium  treatment  for  non-malignant  uterine  bleeding  a  serious,  acute 


SPECIAL    GYNECOLOGIC    DISEASES  531 

pelvic  inflammation  has  rapidly  developed  after  the  application.  This  is  un- 
doubtedly a  manifestation  of  the  power  which  radium  possesses  of  stimulating 
latent  inflammatory  processes.  We  have  already  seen  how  such  an  outcome  may 
follow  the  use  of  radium  in  cervical  cancer.  The  clinical  course  of  such  a  case  is 
exactly  similar  to  that  which  is  often  seen  after  the  injudicious  cureting  of  an 
inflammatory  case.  It  might  be  said,  therefore,  that  the  real  harm  is  done  by 
the  preliminary  curetage  and  not  by  the  radium.  This  may  to  a  certain  extent 
be  true,  but  that  the  radium  is  an  active  agent  in  the  process  is  shown  by  similar 
results  following  radiation  of  cancer  where  the  curet  has  not  been  used. 

"  Menorrhagia  is  a  frequent  accompaniment  of  chronic  pelvic  inflammation 
and  may  occur  in  patients  in  whom  the  disease  of  the  adnexa  cannot  be  detected 
by  the  most  careful  examination.  With  our  present  limited  knowledge  of  the 
technic  of  applying  radium,  it  should  never  be  used  in  inflammatory  cases.  The 
fact  that  such  cases  may  escape  notice  should  always  be  in  the  mind  of  the 
operator.  Fortunately,  a  searching  chnical  history  coupled  with  a  careful  ex- 
amination will,  with  few  exceptions,  reveal  the  presence  of  adnexal  disease. 

Besides  the  menorrhagias,  other  non-malignant  gynecologic  diseases  are  said 
to  be  susceptible  to  radium  treatment.  Most  important  of  these  is  endocervi- 
citis.  The  literature  on  this  subject  is  meager  and  untrustworthy.  On  account 
of  our  inexperience  in  treating  this  condition  with  radium,  and  in  view  of  the 
theoretic  dangers  involved  in  such  treatment,  we  are  not  now  in  a  position  to 
recommend  it.  As  endocervicitis  is,  for  the  most  part,  the  result  of  bacterial 
infection,  radium  would  hardly  appeal  to  one  as  a  logical  means  of  treatment  in 
view  of  its  usual  behavior  in  the  presence  of  inflammatory  processes.  An  addi- 
tional objection  to  making  a  direct  application  of  radium  to  the  endocervix  is  the 
possible  danger  of  creating  an  atresia  of  the  canal.  This  mishap  has  been  re- 
ported following  treatment  of  the  endometrium,  where  the  tube  containing  the 
radium  has  accidentally  slipped  into  the  cervical  canal. 

The  treatment  of  "endometritis"  with  radium  has  also  been  recommended. 
From  what  we  have  seen  of  the  literature  on  this  subject  the  writers  plainly 
employ  the  term  in  its  older  sense  and  include  such  cases  as  we  have  classified 
under  gland  hypertrophy,  which  does  not  represent  a  true  infection.  For  a 
true  endometritis  of  infectious  origin  radium  would,  of  course,  be  contra- 
indicated. 

There  is  excellent  authority  that  radium  may  be  used  beneficially  in  the 
treatment  of  pruritus  and  kraurosis  vulvse. 

Details  of  Treatment. — Dosage. — For  the  menorrhagias  of  women  who  are 
at  the  climacteric  age,  most  authorities  recommend  the  appHcation  in  the  uterine 
canal  of  50  mg.  for  twenty-four  hours.  Some  claim  that  this  dosage  insures  a 
complete  menopause,  but  in  our  experience  such  is  not  always  the  case,  though 
abnormal  bleeding  is  almost  invariably  checked.  On  account  of  the  menopause 
symptoms,  chisfiy  hot  flushes,  which  this  dosage  is  apt  to  set  free,  we  are  accus- 


532  GYNECOLOGY 

tomed  to  apply  50  mg.  for  twelve  or  fourteen  hours  in  the  average  case,  without 
attempting  to  establish  a  complete  menopause,  and  reserve  the  maximum  dosage 
for  the  more  severe  cases  or  those  where  the  full  cessation  of  the  menstrual 
function  is  for  one  reason  or  another  desirable. 

In  women  of  thirty-five  to  forty  we  employ  a  dosage  of  50  mg.  for  eight  to 
ten  hours.  In  patients  twenty-five  to  thirty-five  years  of  age  our  average  dosage 
is  50  mg.  for  four  hours,  but  this  is  increased  or  diminished  according  to  the 
exigencies  of  the  case.  If  the  patient  is  less  then  twenty-five  years  of  age  we 
reduce  the  amount  of  radium  to  25  mg.  and  apply  for  three  to  six  hours. 

This  schedule  is  offered  not  as  an  ideal  standard,  but  only  as  the  scale  that 
we  are  at  present  using  with  apparent  success.  Our  inclination  is  toward  grad- 
ually lessened  dosage. 

After-care. — Following  intra-uterine  applications  of  radium  very  little  after- 
treatment  is  necessary  and  the  patient  is  ready  to  leave  the  hospital  in  three  or 
four  days.  As  a  rule  there  is  more  nausea  and  headache  than  would  be  expected 
after  the  small  amount  of  anesthesia  necessary  for  the  application  of  the  radium. 
Sometimes  the  nausea  ceases  as  soon  as  the  radium  is  removed.  Occasionally 
it  persists  for  tw^o  or  three  daj^s. 

The  patient  should  not  be  allowed  to  urinate  while  the  radium  is  in  the  uterus, 
for  the  vaginal  packing  in  the  vagina  becomes  immediately  soaked  with  urine 
which  may  drain  into  the  uterine  cavity  along  the  rubber  tubing  that  contains 
the  radium.  If  the  application  is  for  eight  to  twelve  hours  the  patient  can  usu- 
ally retain  her  urine  until  the  radium  is  removed.  If  the  patient  is  unable  to 
retain  the  urine  or  the  application  is  to  be  continued  more  than  twelve  hours 
the  bladder  should  be  catheterized. 

The  patient  should  always  be  told  that  she  may  have  a  certain  amount  of 
leukorrhea  following  treatment.  Sometimes  this  is  considerable  and  it  may 
persist  for  five  or  six  weeks.  Vaginal  douches  should  be  prescribed  while  the 
leukorrhea  lasts. 

During  the  first  few  days  some  patients  complain  of  vague  pelvic  pain  re- 
ferred to  one  or  the  other  side.  We  have  not  been  able  to  explain  the  cause  of 
this  pain.    It  soon  passes  away  and  is  not  a  serious  complication. 

Patients  should  also  be  warned  that  there  may  be  some  appearance  of  blood 
during  the  first  few  weeks  after  the  treatment.  This  is  usually  in  the  form  of  an 
occasional  faint  show.  Sometimes  the  first  period  following  even  a  maximum 
dose  may  be  very  profuse. 

One  of  the  most  distinctive  after-effects  is  the "  appearance  of  hot  fiushes. 
They  may  occur  even  in  cases  where  complete  amenorrhea  has  not  been  es- 
tablished. They  indicate  the  influence  which  the  radium  exercises  on  the  ovarian 
tissue.    The  symptom  responds  readily  to  ovarian  extract. 

It  may  happen  in  treating  young  women  that  a  condition  of  menorrhagia 
may  from  overdosage  be  converted  into  one  of  oligomenorrhea.     For  these 


SPECIAL    GYNECOLOGIC    DISEASES  533 

patients  ovarian  extract  in  the  form  of  a  preparation  of  the  whole  ovary  or  of 
ovarian  residue  may  be  given  in  5-grain  doses  three  or  four  times  daily.  The 
treatinent  may  be  continued  indefinitely  if  necessary. 

The  same  treatment  is  indicated  if  by  chance  amenorrhea  should  be  unin- 
tentionally brought  about. 

VAGINISMUS 

By  'Vaginismus"  is  meant  an  involuntary  spasm  of  the  sphincter  cunni  and 
Oither  muscles  of  the  pelvic  floor  awakened  bj^  attempts  at  coitus  or  digital 
examination.  The  spasm  is  usually  accompanied  bj^  a  violent  contraction  of 
the  adductor  muscles  of  the  thigh  and  a  sudden  drawing  back  movement  of  the 
pelvis. 

This  spasmodic  shrinking  from  contact  with  the  vulva  may  be  due  to  an 
actual  hyperesthesia  of  the  external  parts  caused  by  some  painful  lesion,  or  it 
may  be  due  entirely  to  a  psychic  reflex. 

In  the  present  acceptation  of  the  term,  especially  since  the  researches  of 
Walthard,  true  vaginismus  is  applied  only  to  those  cases  in  which  the  mani- 
festation is  purely  psychic.  In  the  other  cases  the  term  "pseudovaginismus"  is 
more  properly  employed. 

Pseudovaginismus  may  be  produced  by  a  variety  of  affections  which  make 
introition  painful,  most  important  of  which  are  urethral  caruncle,  inflammation 
of  Skene's  glands,  hard  unresisting  hymen,  fissure  of  the  vaginal  mucous  mem- 
brane, inflammation  of  Bartholin's  gland,  soft  chancre,  and  other  ulcerations 
of  the  labia,  shrinking  of  the  vaginal  opening  from  senile  atrophy  or  from  cas- 
tration, and  cicatricial  bands  following  improperly  performed  operations  on  the 
perineum. 

In  all  these  cases  contact  of  the  male  organ  or  of  the  examining  finger  is 
exquisitely  painful,  so  that  the  patient  naturally  shrinks  away  to  avoid  pain. 
The  spasmodic  movement  may,  therefore,  be  regarded  as  physiologic,  in  the 
sense  that  it  implies  no  abnormal  psychic  process. 

In  true  vaginismus,  on  the  other  hand,  there  is  present  usually  no  real  hyper- 
esthesia of  the  parts,  the  muscular  spasm  being  the  result  of  a  mental  reflex. 
It  is  often  exhibited  before  actual  contact  with  the  vulva  takes  place.  The 
cause  of  the  reflex  rests  in  the  imagination  and  consists  of  the  fear  of  being  hurt. 
In  many  cases  the  trouble  dates  back  to  some  early  painful  attempt  at  coitus, 
or  to  a  rough  digital  examination,  the  remembrance  of  which  produces  a  lasting 
fear  of  contact.  Other  causes  are  the  fear  of  becoming  pregnant,  personal  dis 
like  of  the  man,  or  an  inborn  abhorrence  of  the  sexual  act,  such  as  is  not  infre- 
quently seen  in  women  of  the  hypoplastic  or  old-maid  type.  In  the  examining 
room  it  is  not  infrequently  found  to  be  the  result  of  shame  and  the  fear  of  detec- 
tion. 


534  GYNECOLOGY 

Abnormal  practices,  like  masturbation  and  coitus  interruptus,  frequently 
lead  first  to  frigidity  and  then  to  true  vaginismus. 

True  and  false  vaginismus  are,  of  course,  closely  related,  and  it  may  some- 
times be  difficult  to  say  which  name  is  applicable  to  a  given  case,  as,  for  example, 
in  a  masturbator  with  secondary  vulvitis.  This  is  especially  true  of  women  of 
middle  age,  who  acquire  vaginismus  after  an  ill-judged  operation  on  the  peri- 
neum or  following  hysterectomy  and  castration.  Here  the  process  is  due  to  an 
atrophy  and  shrinking  of  the  tissue  at  the  introitus  which  is  constantly  uncom- 
fortable, yet  is  not  actually  tender  to  the  touch.  Severe  and  intractable  vaginis- 
mus may,  however,  be  present.  In  these  cases  the  psychic  reflex  is  maintained 
by  the  constant  subjective  discomfort  of  the  perineum.  If  the  discomfort  of  the 
perineum  can  be  eliminated  the  vaginismus  disappears. 

The  treatment  of  pseudovaginismus  is  directed  toward  the  particular  lesion 
which  causes  pain,  and  the  cure  of  the  vaginismus  is,  as  a  rule,  directly  de- 
pendent on  the  cure  of  the  offending  lesion.  Sometimes,  however,  the  patient 
acquires  a  habit  neurosis  and  the  fear  of  coitus  persists,  the  case  becoming  then 
one  of- true  vaginismus. 

The  treatment  of  true  vaginismus  is  a  matter  of  great  difficulty  and  may 
require  the  help  of  an  expert  psychotherapeutist.  It  must  first  be  determined 
by  digital  examination  and  inspection  whether  there  is  any  objective  cause  for 
the  affection.  Examination  of  these  patients  is  a  supreme  test  of  skill,  patience, 
and  tact  on  the  part  of  the  physician.  If  the  patient  makes  the  examination 
impossible,  it  is  necessary  to  resort  to  an  anesthetic.  If  the  examination  without 
ether  is  roughly  or  impatiently  done  the  vaginismus  may  be  made  very  much 
worse.  On  the  other  hand,  if  the  confidence  of  the  patient  is  gained  and  a  suc- 
cessful examination  is  carried  out,  so  that  the  patient  is  convinced  that  there  is 
no  real  tenderness  of  the  parts,  it  may  result  in  a  complete  cure. 

In  order  to  accomplish  this  Walthard  recommends  a  method  of  examination  from  which 
he  claims  much  success.  On  the  theory  of  the  antagonism  of  the  abdominal  muscles  to  those 
of  the  pelvis  he  brings  about  an  "innervation"  of  the  former  by  getting  the  patient  to  exert 
powerful  abdominal  pressure  by  straining  down.  In  this  way  the  muscles  of  the  pelvic  outlet 
are  deadened  so  that  there  is  no  difficulty  in  passing  the  finger  or  an  instrimient  into  the  vagina. 
The  patient,  finding  that  there  is  no  real  pain,  thus  loses  her  fear  of  being  hurt,  which  is  the  chief 
cause  of  the  vaginismus. 

In  the  case  of  vaginismus  due  to  senile  atrophy  of  the  perineum  the  author 
has  had  success  with  ovarian  extract. 

In  the  hypoplastic  type  of  women  stretching  the  introitus  may  help  in  some 
cases,  but,  as  a  rule,  it  is  of  little  value.  These  cases  are,  for  the  most  part,  in- 
curable.    Fortunately,  they  do  not  usually  marry. 

Many  of  the  cases  that  are  due  to  powerful  mental  influences  can  best  be 
treated  by  an  expert  neurologist. 

Dyspareunia  is  a  word  somewhat  loosely  used  to  cover  all  forms  of  unpleasant 


SPECIAL   GYNECOLIC    DISEASES  535 

coitus,  and,  therefore,  commonly  includes  both  true  and  pseudo vaginismus. 
In  its  strictest  sense,  however,  it  denotes  merely  lack  of  pleasure  in  coitus  and 
impUes  absence  of  orgasm.  In  this  sense  dyspareunia  is  dependent  on  defec- 
tive excitability  of  the  clitoris.  It  may  be  caused  by  functional  insensibility  of 
the  pudendal  nerve,  or  of  deficient  excitability  of  the  genitocerebral  ganghon 
or  of  the  genitospinal  ganglion  (Rohleder).  The  same  result  may  be  produced 
by  interruption  of  conduction  from  tabes,  transverse  myelitis,  etc. 

Functional  insensibility  of  the  clitoris  may  be  inherent  and  permanent,  the 
woman  never  experiencing  the  sensation  of  an  orgasm.  Many  women  of  this 
type  show  no  local  or  general  defect  of  development  and  often  bear  children. 
They  are  often  affectionate  and  exhibit  sexual  desire,  but  are  incapable  of  or- 
gasm. 

In  many  women  affection  toward  the  man  plays  a  very  important  part. 
Such  a  woman  may  be  sexually  insensitive  for  years,  and  then,  upon  contracting 
a  new  and  more  congenial  relationship,  awake  to  a  high  degree  of  excitability. 
There  is  no  doubt  that  a  large  percentage  of  women  acquire  a  normal  sensibihty 
of  the  clitoris  only  after  weeks  or  months  of  married  life. 

Dyspareunia  may  be  due  to  masturbation.  In  this  case  the  clitoris  is  insen- 
sitive only  in  coitus.  In  other  cases  it  is  due  to  premature  ejaculation  or  im- 
potence on  the  part  of  the  husband. 

Sexual  insensibility  follows  in  about  20  per  cent,  of  cases  after  hysterectomy 
and  castration.  If  treatment  of  dyspareunia  is  necessary,  it  is  best  carried  out 
by  applying  electricity  to  the  clitoris.     (See  also  section  on  Sexual  Impulse.) 

GYNATRESIA 

Atresia  of  the  vagina  relates  to  a  complete  closure  of  the  vaginal  canal. 
The  closure  may  take  place  at  any  point  of  the  vagina  from  the  cervix  to  the 
hymen,  or  it  may  constitute  an  obliteration  of  the  entire  canal.  It  is  quite 
commonly  believed  that  most  atresias  of  the  vagina  are  the  result  of  some  con- 
genital defect.  This  has  been  shown  to  be  an  error,  and  it  is  now  known  that 
in  the  great  majority  of  cases  the  closure  is  the  result  of  an  inflammation  and 
ulceration  of  the  vaginal  walls,  during  the  heahng  of  which  the  contiguous  sur- 
faces of  the  vagina  become  permanently  adherent. 

A  study  of  the  embryology  of  the  genital  system  proves  that  with  a  normally 
developed  uterus  there  can  be  no  defect  of  the  vagina,  excluding  the  cases  of 
double  formation.  When  there  is  absence  of  the  vagina  the  upper  portions  of 
the  genital  tract  are  necessarily  rudimentary  and  do  not  functionate.  Congenital 
absence  of  the  vagina  is,  therefore,  symptomless. 

Conversely,  atresia  of  the  vagina,  accompanied  by.  symptoms  of  obstructed 
secretions,  implies  a  full  development  of  the  genital  system,  and  the  closure  of 
the  vagina,  must,  therefore,  be  considered  acquired  (Veit). 


536  GYNECOLOGY 

There  is  one  exception  to  this  (Veit).  It  is  evident  that  there  may  be  a  union 
of  the  epithehal  surfaces  of  the  hymen  before  birth  in  the  presence  of  normal  de- 
velopment of  the  rest  of  the  genital  tract.  Whether  this  closure  is  due  to  an 
intra-uterine  infection,  or  whether  it  is  a  congenital  defect,  has  not  been  de- 
finitely settled.  This  form  of  atresia  is  seen  in  the  newborn,  and  makes  its 
appearance  by  the  extrusion  of  a  tumor  from  the  labia,  consisting  of  blood- 
stained secretions  retained  behind  the  occluded  hymen,  which  is  stretched  out 
into  a  thin  membrane  by  the  pressure  of  the  fluid.  Evacuation  of  the  fluid 
contents  by  incision  of  the  membrane  is  imperative  within  a  few  days  after 
birth. 

According  to  Veit,  intra-uterine  closure  of  the  hymen  is  always  evident  at 
the  time  of  or  soon  after  birth,  and  cases  that  produce  symptoms  later  must  be 
regarded  as  the  result  of  an  acquired  atresia. 

There  is  also  one  other  apparent  exception  to  the  statement  that  a  develop- 
ment of  the  lower  vagina  cannot  exist  with  rudimentary  internal  genital  organs. 
In  cases  of  deficient  vagina  it  is  not  infrequently  observed  that  attempts  at 
coitus  may  create  a  blind  pouch  in  the  vulva  that  suggests  a  true  vagina. 

The  ways  in  which  the  vagina  and  hymen  may  become  closed  as  the  result 
of  plastic  healing  of  inflammatory  processes  are  numerous.  In  children  the 
atresia  usually  takes  place  either  at  the  hymeneal  opening  or  at  the  junction  of 
the  middle  and  outer  third  of  the  vaginal  canal,  where  the  anterior  and  posterior 
surfaces  lie  most  intimately  together.  The  causes  assigned  for  this  process  are 
necessarily  some  of  them  theoretic,  but  entirely  plausible.  The  mucous  mem- 
brane of  the  vagina  and  vulva  in  childhood  is  very  dehcate  and  plastic.  It  may 
well  be  imagined  that  chafing  and  erosion  at  the  small  opening  of  the  introitus 
irritated  by  the  urine,  or  infected  by  thin  fecal  material,  might  easily  result  in 
gluing  together  of  the  edges  of  the  hymen  or  even  of  the  surfaces  of  the  labia 
minora.  The  injury  to  the  surface  epithehum  might  be  the  result  of  trauma, 
like  that  of  falling  astride  a  fence,  or  it  might  be  from  masturbation,  or  even 
from  the  chafing  of  muscular  movements.  Atresia  at  the  introitus  results 
in  a  thin  "membrane  when  pressed  upon  and  stretched  by  the  obstructed 
secretions. 

In  atresia  that  takes  place  inside  the  vagina  there  is  a  broader  area  of  adhe- 
sion,-which  varies  from  a  narrow  strip  of  adherent  surface  to  one  whose  width 
includes  nearly  the  length  of  the  vaginal  canal.  The  membrane  or  diaphragm 
stretched  out  by  the  secretions  is  thicker  and  more  cicatricial  than  that  of  hy- 
meneal atresia. 

Stenosis  of  the  vagina  is  produced  by  the  same  causes  as  atresia,  and  relates 
to  a  condition  where  the  obstruction  is  not  complete.  When  due  to  an  early 
vaginitis  an  annular  constricting  ring  of  scar-tissue  may  be  felt,  through  which 
the  finger  can  usually  be  passed.  Severe  lacerations  of  the  vagina  from  instru- 
mentation at  childbirth  may  be  followed  by  extensive  obstructive  scarring  of  the 


SPECIAL   GYNECOLOGIC    DISEASES  537 

vagina,  the  scars  sometimes  extending  into  the  parametrium.  Partial  atresia 
from  senile  vaginitis  is  very  common. 

The  effect  of  cicatricial  stenosis  of  the  vagina  is  to  cause  incomplete  drain- 
age of  the  secretions,  which  become  stagnant  and  chemicallj^  altered.  The 
result  is  an  irritating  leukorrhea.  This  is  a  not  uncommon  cause  of  pruritus 
and  kraurosis. 

A  most  important  danger  from  cicatricial  stenosis  of  the  vagina  is  that 
from  dystocia. 

As  has  been  said,  occluding  adhesions  of  the  vaginal  walls  presuppose  some 
form  of  ulcerative  vaginitis.  The  most  important  and  severe  form  of  vaginitis 
that  occurs  in  childhood  is  that  caused  by  the  gonococcus.  The  vulva  and 
vagina  in  childhood  is  extraordinarily  susceptible  to  this  organism,  and  infec- 
tions easily  take  place  from  unclean  towels,  sponges,  bed-linen,  etc.  The 
resultant  inflammation  is  usually  productive  of  profuse  suppuration  and  tend- 
ency to  plastic  adhesions.  One  observer  (Frankel)  asserts  that  the  sjmiptoms  of 
gonorrheal  vaginitis  in  children  may  be  so  shght  as  not  to  be  noticeable,  and 
that  in  this  way  many  unaccountable  atresias  take  place.  This  seems  reason- 
able when  one  considers  the  extensive  occluding  processes  which  the  disease 
may  produce  in  other  tissues  with  almost  inappreciable  symptoms. 

It  has  been  shown  that  various  general  infectious  diseases  may  cause  in- 
flammatory and  ulcerative  processes  in  the  vagina,  such  as  scarlet  fever,  diph- 
theria, typhoid,  and  even  measles,  and  it  is  not  unhkely  that  fnany  cases  of 
vaginal  atresia  in  childhood  are  referable  to  these  diseases. 

Veit  cites  several  interesting  cases  to  show  how  readily  the  hymen  may  become  closed. 
In  one  case  at  the  end  of  pregnancy  a  complete  atresia  of  the  hymen  was  fomid.  Others  of  a 
hke  nature  are  quoted.  In  another  case,  a  girl  of  twenty  had  menstruated  regularly  for  several 
years  and  then  became  amenorrheic.  It  was  found  that  she  had  acquired  an  atresia  of  the 
hjTnen  with  a  hematocolpos.  In  adult  life  atresia  of  the  vagina  may  be  the  result  of  severe 
lacerations  and  inflammations  of  the  vagina  following  the  instrumentation  of  childbirth. 

After  the  menopause,  senile  vaginitis  may  result  in  atresia  of  the  vagina  and 
more  often  atresia  of  the  cervix.  In  this  form  the  occlusion  is  more  apt  to  occur 
at  the  upper  portion  of  the  vagina.  The  process  of  atrophy  obhterates  the  pos- 
terior vaginal  pouch  and  makes  the  vagina  conical.  The  plastic  process  of  the 
chronic  inflammation  tends  to  glue  the  walls  to  the  cervix  and  narrow  or -close 
the  vaginal  lumen  near  the  external  os. 

Sjntnptoms. — Hymenatresia  of  the  newborn  is  attended  with  a  backing  up  of 
the  secretions  in  the  vagina  and  consequent  protrusion  of  the  obstructing 
membrane.  This  is  due  to  the  fact  that  the  uterus  is  stimulated  at  birth  to 
hypersecretion  and  even  bleeding,  probably  through  the  agency  of  the  placenta. 
After  birth  the  uterus  usually  remains  inactive  until  puberty,  so  that  postnatal 
acquired  atresia  does  not  produce  symptoms  until  that  time,  although  a  few 
cases  have  been  reported  where  non-hemorrhagic  secretions  have  collected  be- 
hind the  closure  and  required  attention  before  the  onset  of  menstruation. 


538 


GYNECOLOGY 


Usually  the  affection  first  makes  itself  evident  when  the  patient  has  begun 
to  menstruate.  Each  month  there  occur  the  mohmina  of  menstruation  at- 
tended with  severe  cramp-like  pains  in  the  lower  abdomen  and  back.  Some- 
times there  are  no  subjective  symptoms  until  so  great  a  mass  has  collected  as  to 
cause  pressure. 

If  the  atresia  is  at  the  hymen  or  low  in  the  vagina  the  obstructed  menstrual 
blood  and  uterine  and  cervical  secretions  collect  in  the  vagina,  forming  a  so- 
called  "hematocolpos."  The  atretic  membrane  is  ballooned  outward  between  the 
labia,  while  the  mass  in  the  vagina  may  reach  an  enormous  size.  In  time  the 
cervix  becomes  stretched  out,  and  eventually  the  uterus  is  filled  and  distended 
with  blood,  forming  a  hematometra. 


'N/vi.p.fexo.wes 


.\jmen. 


FiG.  209  —Acquired  Atresia  of  the  Vagina  or  Hymen. 
A  semidiagram  showing   the  cavities  formed  in  the  genital  tract  by  the  obstructed  menstrual 
blood.     Hematocolpos  in  the  vagina,  hematometra  in  the  body  of  the  uterus,  and  hematosalpinx  in 
the  tubes. 

A  later  and  more  serious  manifestation  is  the  formation  of  a  hematosalpinx 
on  one  or  both  sides.  The  hematosalpinx  is  produced  by  a  closure  of  the  ostium 
and  an  exudation  of  blood  into  the  lumen.  This  blood  comes  partly  from  the 
flow  from  the  uterus  and  also,  as  has  been  proved,  from  hemorrhages  from  the 
tubal  mucosa.  How  the  tubal  ostium  becomes  closed  is  a  matter  of  some  doubt. 
Some  believe  that  it  can  only  be  explained  as  a  part  of  the  original  inflamma- 
tory process  which  caused  the  atresia  of  the  vagina.  Others  maintain  that  the 
tubal  end  may  become  closed  without  the  agency  of  infectious  micro-organisms 
by  the  clotting  and  organization  of  blood,  as  sometimes  happens  in  tubal  abor- 
tion.     Others  think  that  the  epithelial  lining  of  the  ends  of  the  tubes  desqua- 


SPECIAL   GYNECOLOGIC   DISEASES 


539 


mates  as  a  result  of  chronic  congestion  and  thus  favors  adhesion.  Thoma  be- 
heves  that  the  collection  of  blood  in  the  genital  organs  decreases  the  absorptive 
power  of  the  pelvic  peritoneum,  which  is  kept  in  a  condition  of  chronic  irritation 
by  the  repeated  exudation  on  its  surface  of  menstrual  blood.  Thus,  adhesions 
are  formed  from  chemicotraumatic  influence.  The  hematosalpinx  may  be- 
come adherent  to  the  intestines  and  be  infected.  The  contained  blood  undergoes 
a  characteristic  change.  The  blood-corpuscles  shrink  and  the  blood  itself  be- 
comes thick  and  syrupy,  assuming  a  chocolate  appearance. '  If  infection  takes 
place  the  hematosalpinx  is  converted  into  a  pyosalpinx. 

The  long-retained  blood  is  very  toxic,  and  in  some  cases  probably  contains 
pathogenic  micro-organisms,  for  if  rupture  of  the  tube  occurs  the  event  is  apt  to 
be  fatal,  either  from  peritonitis  or  toxic  absorption.  The  rupture  may  be  fol- 
lowed by  shock  and  death  like  that  from  a  ruptured  tubal  pregnancy. 

The  diagnosis  of  atresia  during  puberty  is  usually  obvious.  Periodic  moli- 
mina  of  menstruation,  with  pain  and  no  appearance  of  blood,  occlusion  of  the 
vagina,  and  pelvic  mass  felt  by  rectum,  form  a  characteristic  chnical  picture. 
It  is,  however,  not  always  easy  to  judge  the  extent  of  the  trouble,  especially  as 
regards  the  involvement  of  the  tubes.  The  large  abdominal  mass  is  sometimes 
indefinite  and  the  cUstended  organs  cannot  readily  be  differentiated. 

Treatment. — Atresia  of  the  hymen  and  vagina  should  always  be  treated  by 
a  radical  operation — i.  e.,  complete  excision  of  the  occluding  membrane— 
except  where  there  is  atresia  of  the  entire  canal,  in  which  case  such  an  opera- 
tion is,  of  course,  not  feasible.  The  contents  of  the  vagina  and  uterus  should 
then  be  thoroughly  evacuated  under  the  most  careful  aseptic  precautions.  By 
entirely  excising  the  membrane  free  drainage  is  established  and  the  patient  is  in 
little  danger  of  sepsis.  Moreover,  there  is  no  danger  of  recurrence  of  the  atresia. 
The  common  practice  of  opening  the  membrane  by  a  crucial  incision  without 
further  operation  is  very  much  to  be  condemned.  This  method  does  not  pro- 
vide free  drainage  and  sepsis  ensues  without  fail.  The  sepsis  may  be  fatal  or 
it  may  lead  to  a  long  process  of  chronic  vaginitis,  with  continuous  foul  leukor- 
rhea  from  the  partially  retained  secretions.  Moreover,  the  incised  wound 
made  by  the  scalpel  through  the  membrane  soon  contracts  to  a  small  opening 
which  further  hinders  free  drainage.  The  proper  method  of  excising  the  mem- 
brane is  shown  on  page  665. 

If  the  surfaces  of  the  vagina  have  grown  completely  together  the  separation 
of  the  two  walls  may  leave  them  with  little  or  no  epithelial  covering.  The  prob- 
lem then  becomes  a  very  difficult  one,  for  it  sometimes  is  impossible  to  keep  the 
lumen  from  closing  up  without  grafting  a  new  epithelial  covering.  This  may  be 
accompUshed  by  turning  in  flaps  from  the  labia  minora  and  thighs,  as  depicted 
on  page  668.  Even  this  may  not  be  feasible,  and  it  may  become  necessary  to 
perform  a  complete  hysterectomy. 

If  hematosalpinx  is  present  the  condition  is  to  be  regarded  as  very  serious. 
This  requires  an  abdominal  operation  in  addition  to  the  vaginal  operation  for 


540  GYNECOLOGY 

removal  of  the  membrane.  The  question  then  arises  as  to  which  operation  to  do 
first.  Opinions  differ  in  this  respect.  In  our  own  practice  we  prefer  to  do  the 
vaginal  operation  first,  partly  because  one  cannot,  as  a  rule,  be  perfectly  sure  as 
to  whether  or  not  hematosalpinx  is  present,  a  diagnosis  of  which  can  easily  be 
made  after  the  vagina  has  been  opened.  A  second  reason  is  that  the  pelvic  con- 
dition may  require  a  hysterectomy,  which  if  done  first  would  result  in  spilhng 
the  blood  contained  in  the  uterus  and  vagina  into  the  peritoneal  cavity. 

In  operating  on  young  girls  for  hematosalpinx  it  is  important  to  be  conserva- 
tive if  possible,  but  the  extent  of  the  operation  must  be  determined  by  the  exi- 
gencies of  the  case. 

In  treating  the  hematosalpinx  it  is  safest  to  regard  the  case  as  one  of  sepsis 
and  to  leave  in  a  precautionary  drain  in  the  lower  end  of  the  abdominal  incision. 
Drainage  should  not  be  established  through  the  vagina,  as  in  the  usual  case  of 
pelvic  sepsis. 

Atresia  sometimes  occurs  on  one  side  of  double  uterus  and  vagina.  The 
closure  may  be  the  result  of  congenital  union  or  it  may,  like  atresia  of  the  simple 
vagina,  be  acquired,  and  in  the  same  way.  In  this  type  of  atresia  the  hemato- 
metra  and  hematosalpinx  are  one-sided,  with  consequent  unilateral  symptoms. 
The  diagnosis  may  be  quite  obscure,  as  the  other  uterus  may  menstruate  nor- 
mally without  obstruction. 

The  treatment  is  removal  of  the  offending  organ  by  a  laparotomy. 

The  treatment  of  stenosis  is  to  excise  the  scar-tissue  as  completely  as  possible. 
It  is  important  to  sew  up  the  wounds  in  the  vaginal  wall  in  such  a  way  as  to  avoid 
causing  a  new  constriction.  This  requires  ingenuity  and  knowledge  of  plastic 
surgery  on  the  part  of  the  operator.  It  most  cases  it  is  possible  to  restore  the 
vagina  to  its  normal  caliber  and  consistency,  but  the  scars  may  be  so  deep  as  to 
make  the  operation  dangerous  and  the  results  unsatisfactory. 

The  treatment  of  congenital  absence  of  vagina  is  indicated  when  it  is  desir- 
able to  create  an  artificial  vagina  for  the  purposes  of  cohabitation.  Many 
women  with  absent  vagina  and  rudimentar}^  internal  genitals  are  perfectly 
developed  as  regards  their  secondary  sexual  characteristics,  and  are  endowed 
with  normal  sexual  inclinations  and  sensibility.  Such  patients  are  often  ready 
to  take  any  risk  in  order  to  become  marriageable.  The  various  operations  for 
estabhshing  an  artificial  vagina  are  described  in  Part  III. 

GENITAL  ATROPHY 

The  clinical  importance  of  the  pathologic  changes  that  may  result  from 
atrophy  of  the  female  genitals  is  not  suflficiently  recognized,  and  for  that  reason, 
in  order  to  direct  attention  to  it,  a  special  section  is  devoted  to  the  subject. 

Under  normal  physiologic  conditions  senile  involution  of  the  internal  and 
external  genital  organs  begins  at  the  time  of  the  climacteric,  and  proceeds 
gradually  to  degrees  varying  in  different  individuals. 


SPECIAL   GYNECOLOGIC    DISEASES 


541 


In  the  uterus  the  muscle  elements  of  the  wall  diminish  and  become  pro- 
portionately less  than  the  connective  tissue.  The  entire  organ  becomes  shorter, 
thinner,  and  more  flaccid,  finally  shrinking  to  a  mere  sac,  while  the  surface 
assumes  a  pale  and  anemic  appearance. 

The  position  of  the  atrophied  uterus  is  always  that  of  the  second  degree  of 
retroversion — i.  e.,  pointing  in  the  direction  of  the  axis  of  the  vagina,  and  the 
axis  of  the  uterus  is  practically  straight. 


Fig.  210. — Ateophy  of  the  Tube. 
Low  power  near  junction  of  middle  and  isthmic  portions  of  the  tube.    The  villi  have  disappeared, 
leaving  a  nearly  round  lumen  which  is  lined  by  a  layer  of  low  epithelial  cells  which  are  inactive.     There 
is  a  distinct  layer  of  connective  tissue  taking  the  place  of  the  stroma  of  the  villi  between  this  epithelial 
layer  and  the  muscular  wall  of  the  tube. 


The  mucous  membrane  shares  in  the  general  mvoiution  and  becomes  thin 
and  smooth.  The  glandular  elements  diminish  in  size  and  number  and  finally 
disappear  altogether,  while  the  ciliated  surface  epithelium  is  transformed  to  a 
low  cuboidal  type  without  cilia.  The  stroma  of  the  endometrium  shrinks  and 
takes  on  the  spindle-form  type  of  connective  tissue.  The  cervix  becomes  smaller 
and  less  prominent,  and  in  time  may  appear  only  as  a  dimple  in  the  vault  of  the 


542 


GYNECOLOGY 


vagina.  The  uterine  canal  also  diminishes  in  caliber,  and  may  become  partially 
or  completely  obstructed.  The  tubes  are  shorter  and  straighter,  while  the 
ovaries  shrivel  up  into  insignificant  bundles  of  connective  tissue,  with  complete 
disappearance  of  the  follicles. 

The  folds  and  rugae  of  the  vagina  flatten  out,  and  the  vault  of  the  vagina, 
formerly  broad  and  pouch-hke,  becomes  narrow  and  pointed,  with  gradual  ob- 
literation of  the  receptaculum.  The  vaginal  secretion  after  the  senile  change 
becomes  alkaKne  instead  of  acid,  and,  therefore,  less  hostile  to  pathogenic  bac- 
teria. The  introitus  shrinks  to  a  smaller  cahber,  and  if  there  are  scars  from  old 
operations  they  contract  into  cord-like  bands. 


Fig.  211. — Atrophy  of  the  Ovary. 
Very  low  power.     Section  of  the  whole  ovary,  showing  at  the  bottom  the  hilus,  which  contains 


many  blood-vessels  having  thick  walls  and  undergoing  obliteration, 
albicantia.     The  cortex  is  thin  and  poorly  defined. 


At  the  top  are  many  corpora 


The  external  genitals  show  a  marked  change.  The  labia  majora  lose  their 
rotund  contour  and  become  flat  and  wrinkled.  The  labia  minora  become  thin 
and  flat  and  gradually  diminish  in  size  until  they  disappear.  The  epidermis  of 
the  vestibule  and  labia  minora  assumes  a  pale  anemic  appearance  and  becomes 
dry  and  inelastic. 

Senile  involution  of  the  genitals  usually  does  not  make  its  appearance  until 
after  the  age  of  forty,  but  moderate  grades  of  it  are  sometimes  seen  even  at  the 
age  of  thirty  in  women  who  show  no  other  abnormality. 


SPECIAL   GYNECOLOGIC    DISEASES  543 

Another  form  of  physiologic  atrophy  is  that  which  to  a  greater  or  less  degree 
is  always  associated  with  lactation  and  is  most  noticeable  in  the  uterine  wall. 
This  is  practically  a  hyperin volution,  for  it  has  been  shown  (Saenger)  that  the 
smaller  size  of  the  uterus  is  due  not  to  a  destruction  of  the  musculature,  as  in 
senile  atrophy,  but  to  a  diminution  in  size  of  the  separate  muscle-fibers.  When 
lactation  ceases,  therefore,  the  uterus  normally  regains  its  former  volume. 
During  lactation  the  uterus  is  soft  and  flaccid  and  easily  punctured  or  lacerated, 
a  point  to  be  remembered  if  surgical  instrumentation  is  required  during  that 
period. 

Lactation  atrophy  probably  always  includes  to  some  extent  all  of  the  genital 
tract,  but  it  may  be  so  slight  as  not  to  be  particularly  noticeable.  If,  however, 
a  plastic  operation  is  performed  on  the  external  genitals  at  that  time  the  lack  of 
elasticity  of  the  tissues  is  usually  quite  evident,  and  may  interfere  somewhat 
with  securing  the  best  results.  This  is  a  practical  point  to  remember,  especially 
in  the  repair  of  complete  lacerations,  where  the  inelasticity  of  the  atrophied 
tissues  may  prevent  exact  approximation  and  good  union. 

If  lactation  is  greatly  prolonged  or  frequently  repeated  by  rapid  childbear- 
ing,  the  atrophy  may  become  permanent  and  even  result  in  amenorrhea  and 
sterility.  Premature  genital  atrophy  is  usually  due  to  this  cause.  Lactating 
women  with  tuberculosis  are  especially  prone  to  permanent  atrophy  (Kiistner). 

A  third  form  of  atrophy  is  that  due  to  castration.  This  form  is  identical 
in  its  phj^siologic  processes  with  the  senile  type.  It  is  more  marked  in  women 
approaching  the  natural  menopause  than  in  younger  women.  It  often  takes 
place  very  rapidly  after  the  operation  of- castration,  anemia  and  drying  of  the 
external  genitals  sometimes  being  noticed  within  two  weeks  after  the  operation. 

Pathologic  genital  atrophy  may  be  the  result  of  constitutional  diseases,  the 
most  important  of  which  is  pulmonary  tuberculosis.  Other  diseases  which  are 
said  to  act  in  the  same  way  are  chronic  nephritis,  diabetes,  morphinism,  articular 
rheumatism,  diseases  of  the  spinal  cord,  cachexia  strumapriva,  and  severe 
psychic  disturbances. 

Severe  puerperal  sepsis  of  the  uterus  may  cause  a  loss  of  uterine  wall  tissue 
by  necrosis,  and  thus  produce  a  mechanical  form  of  atrophy  (Kiistner). 

The  etiology  of  genital  atrophy  is  referred  to  suppression  of  the  internal 
secretion  of  the  ovaries,  one  of  the  chief  functions  of  which  is  to  preside  over  the 
integrity  of  the  other  genital  organs.  It  seems  probable  that  the  atrophy  is 
caused  by  a  local  anemia  of  the  parts  which  inevitably  ensues  as  a  result  of  hy- 
pof unction  of  the  ovaries. 

Genital  atrophy,  being  for  the  most  part  a  physiologic  process,  as  a  rule 
gives  no  trouble,  but  it  ma}^  under  certain  conditions  produce  complications  that 
are  of  serious  clinical  significance. 

One  of  the  most  important  of  these  is  the  shrinkage  of  the  cervical  canal, 
which  may  result  in  a  partial  or  complete  atresia.  Closure  of  the  canal  is  espec- 
ially apt  to  occur  in  cervices  that  long  before  have  been  repaired  for  lacerations. 


544  GYNECOLOGY 

Complete  closure  causes  sometimes,  though  not  always,  a  backing  up  in  the 
uterine  canal  of  the  serous  secretion  of  the  endometrium  and  produces  a  so- 
called  hydrometra.  If  before  complete  closure  an  ascending  infection  takes 
place,  the  contents  of  the  canal  become  purulent  and  the  conchtion  is  then  one 
of  pyometra.  Usually  the  atresia  of  the  canal  is  incomplete,  so  that  the  con- 
tents are  retained  only  temporarily  and  are  then  discharged  more  or  less  period- 
ically. This  interruption  of  free  drainage  from  the  uterus  favors  infection  and 
chemical  change  in  the  secretions,  so  that  they  become  very  irritating.  The 
periodic  discharge  from  a  pyometra  may  be  extremely  fetid  and  simulate  the 
characteristic  odor  of  malignant  disease  of  the  cervix.  For  this  reason  these 
cases  are  very  frequently  diagnosed  as  cancer. 

The  irritating  uterine  discharge  is  instrumental  in  macerating  the  vaginal 
epithelium,  which  is  thin  and  desquamates  easily,  thus  producing  a  senile 
vaginitis.  The  cheinical  effect  of  the  discharge  on  the  vulva  is  productive  of 
pruritus,  and  if  sufficiently  prolonged  may  cause  permanent  changes  in  the 
cuticle  such  as  have  been  described  under  Kraurosis  (q.  v.). 

Senile  vaginitis  may  result  from  the  irritation  of  retained  secretions  from  the 
uterus,  or  it  may  develop  independently  as  a  sequel  of  senile  atrophy.  The 
thin,  easily  desquamating  epithelium  is  readily  macerated  by  friction  and  in- 
fected by  the  bacteria  that  have  their  habitat  in  the  vagina.  A  thick,  white 
discharge  is  produced,  usually  of  a  foul  odor,  the  consistency  and  color  of  the 
discharge  being  due  to  a  great  amount  of  desquamated  vaginal  epithehum.  The 
destruction  of  the  epidermis  is  locahzed  in  various  areas  of  the  vagina,  which 
may  appear  either  as  mottled  red  spots  or  may  sometimes  present  fissures  or 
ulcers.  If  the  destruction  of  the  epidermis  is  sufficiently  deep,  mild  hemor- 
rhages are  produced,  so  that  the  discharge  becomes  tinged  with  blood,  an  appear- 
ance that  is  still  further  suggestive  of  cancer. 

Senile  vaginitis,  like  that  seen  in  children,  has  a  marked  tendency  to  form 
plastic  adhesions  in  the  vagina.  In  senile  vaginitis,  however,  the  adhesions 
usually  form  in  the  upper  part  of  the  vagina,  in  contrast  to  those  of  the  infantile 
type,  which  form  at  or  below  the  lower  third  of  the  canal. 

The  vault  of  the  vagina  may  become  intimately  attached  to  the  cervix  so  as 
to  bury  it  almost  completely,  or  the  walls  may  adhere  in  such  a  way  as  to  form  a 
partial  or  complete  atresia  of  the  canal.  The  process  may  extend  to  the  vaginal 
portion  of  the  cervix  and  seal  over  the  external  os,  causing  conditions  similar 
to  those  described  under  constriction  and  atresia  of  the  cervical  canal,  namely, 
hydro-  or  pyometra. 

Genital  atrophy  causes'*  a  shrinking  and  narrowing  of  the  vaginal  introitus, 
and  if  there  happen  to  be  strands  of  scar-tissue  in  the  perineum,  such  as  may  have 
resulted  from  earlier  operations,  they  tend  to  contract  into  dense  unyielding 
cords  that  may  be  a  source  of  great  discomfort  in  various  ways.  The  patient 
may  be  conscious  of  a  tight  drawing  sensation,  which,  by  incessantly  holding 
her  attention,  may  produce  a  severe  form  of  genital  neurosis. 


SPECIAL   GYNECOLOGIC   DISEASES  545 

The  tight  cord-Hke  obstruction  to  the  vaginal  introitus  makes  coitus  painful 
or  impossible,  and  causes  marital  unhappiness  and  sexual  neuroses. 

The  cicatricial  perineum  may  act  as  a  dam  to  interfere  with  the  free  drainage 
of  the  vaginal  and  uterine  secretions,  with  resulting  vaginitis  and  external 
irritation.  The  cicatricial  perineum  is  nearly  always  the  later  result  of  an 
overzealous  perineoplasty  which  has  drawn  the  perineum  too  tightly  at  one 
or  more  points,  so  as  to  create  a  sharp  ridge.  Such  a  perineum  may  not  give 
much  trouble  until  the  natural  menopause  or  until  the  patient  undergoes  a 
pelvic  operation  involving  the  removal  of  the  ovaries. 

When  a  perineoplasty  is  done  at  the  same  time  as  a  hysterectomy  the  peri- 
neum, if  closed  too  tightly,  may  shrink  and  give  trouble  soon  after  the  operation. 

The  practical  lesson  from  these  cases  impresses  the  importance  of  a  proper 
technic  in  perineoplastic  operations.  The  sharp,  cord-like  scar  formation  may 
result  from  sepsis  and  healing  by  granulation,  or  it  may  be  due  to  drawing  the 
wound  edges  too  tightly  in  consequence  of  an  injudicious  denudation.  It  is  to 
be  remembered  that  the  scarring  is  subcutaneous,  and  does  not  reach  into  the 
muscular  elements,  which  cannot  be  approximated  too  closely.  A  repaired 
perineum  which  presents  a  smooth  funnel-shaped  introitus  is  not  likely  to  give 
trouble  from  atrophy.  This  result  can  be  attained  in  a  perineoplasty,  if  it  be 
remembered  that  the  real  support  of  the  perineum  must  be  sought  for  in  the 
union  of  the  levator  ani  muscles  and  not  in  the  tense  approximation  of  super- 
ficial tissues. 

Senile  atrophy  may  cause  trouble  in  the  vestibule  of  the  vulva.  This  is 
shown  especially  in  the  effect  which  the  shrinking  of  the  tissues  has  on  the 
urethra.  The  urethral  mucous  membrane  may  be  literally  dragged  outward  by 
the  contraction  of  the  epidermis  of  the  vestibule,  forming  an  eversion  or  ec- 
tropion, a  condition  that  has  somewhat  the  appearance  of  a  urethral  caruncle. 
It  usually  gives  little  trouble,  but  the  pouting  membrane  may  become  irritated 
and  cause  great  annoyance.  In  extreme  cases  thrombosis  and  gangrene  of  the 
prolapsed  mucous  membrane  may  occur,  requiring  surgical  interference. 

True  caruncles  are  especially  apt  to  form  in  wojnen  who  have  genital  atrophy. 

The  general  process  of  atrophy  involves  also  the  urethra  and  bladder.  In 
the  urethra  a  stricture  may  result,  while  in  the  bladder  the  wall,  losing  its  elas- 
ticity, shrinks  and  causes  a  diminution  in  the  capacity  with  consequent  fre- 
quency and  discomfort  of  micturition. 

The  most  distressing  symptom  of  senile  atrophy  is  that  which  comes  from 
the  vulval  epidermis,  especially  that  portion  immediately  around  or  just  at  the 
introitus.  The  sensation  is  one  of  heat  and  dryness  in  some,  and  in  others  an 
intense  itching  or  pruritus.  As  stated  above,  it  is  probably  due  to  the  chemical 
effect  of  the  retarded  secretions,  though  it  is  sometimes  seen  where  there  is  no 
appreciable  vaginal  discharge.  The  result  is  a  form  of  vaginismus  that  may 
be  a  source  of  great  nervous  irritation.  The  constant  occupation  of  the  patient's 
attention  on  the  perineal  discomfort  with  no  apparent  lesion  sometimes  leads  to 

35 


546  GYNECOLOGY 

the  diagnosis  of  a  pure  neurosis.  The  patients  no  doubt  acquire  neurotic  habits 
and  overvalue  their  uncomfortable  sensations,  but,  hke  other  genital  neuroses, 
the  nervous  irritability  has  a  definite  physical  basis  in  continual  nagging  dis- 
comfort. 

The  diagnosis  of  changes  due  to  senile  atrophy  is  usually  simple,  the  numer- 
ous mistakes  that  are  made  by  practitioners  being  due  to  the  fact  that  the  dis- 
ease has  not  been  sufficiently  brought  to  their  attention. 

The  disease  for  which  genital  atrophy  is  most  commonly  mistaken  is  cancer. 
The  appearance  of  a  foul,  bloody  discharge  after  the  menopause  is,  of  course, 
most  suggestive  of  malignancy.  Usually  a  bimanual  examination  settles  the 
matter  definitely  by  revealing  the  smooth  vagina,  the  atrophied  cervix,  and  the 
small  flexible  uterus.  One  should  always  be  on  guard,  however,  not  to  miss 
the  inverting  form  of  cancer  of  the  endocervix,  which  in  the  early  stages  may  not 
be  apparent  to  touch  or  sight.  In  the  same  way  adenocarcinoma  of  the  body 
may,  and  often  does,  originate  in  an  atrophied  uterus.  In  all  cases,  therefore, 
where  there  is  a  suspicion  of  cancer  an  intra-uterine  examination  should  be 
made  with  the  curet  under  an  anesthetic.  Such  an  examination  is  important 
also  in  determining  and  treating,  if  present,  atresia  of  the  cervical  canal. 

In  determining  the  underlying  cause  of  pruritus  and  kraurosis  it  i'S  all 
important  to  search  for  possible  obstructions  of  the  secretions  in  the  vagina 
and  cervix. 

Ulcers  and  fissures  of  the  atrophied  vaginal  membrane  may  resemble  malig- 
nant disease.  The  diagnosis,  on  the  least  suspicion,  should  be  made  by  micro- 
scopic examination  of  an  excised  specimen  of  tissue. 

Treatment. — In  treating  the  complications  due  to  genital  atrophy  it  should 
be  a  routine  measure  to  anesthetize  the  patient  and  explore  the  uterine  canal, 
partly  with  the  purpose  of  ruling  out  cancer  and  partly  with  the  purpose  of 
finding  and  dilating  possible  strictures  of  the  canal.  These  strictures  occur 
much  more  commonly  than  is  supposed.  Though  they  may  not  constitute  a 
complete  atresia,  yet  they  may  interfere  with  good  drainage.  If  an  unsuspected 
cervical  stricture  does  exist,  treatment  of  the  vagina  and  vulva  may  go  on  in- 
definitely without  doing  the  least  good. 

As  a  rule,  dilatation  of  the  cervical  canal  is  enough.  If  the  stricture  or 
atresia  is  near  or  at  the  external  os  an  artificial  bilateral  laceration  may  be  made 
in  the  cervix,  so  as  to  give  the  canal  a  tube-shaped  outlet. 

If  pyometra  is  present  the  dilatation  may  be  followed  by  a  recurrence  of  the 
old  process.     If  this  happens  a  hysterectomy  is  indicated. 

If  there  is  a  vaginitis  it  is  necessary  first  to  determine  whether  the  inflam- 
mation is  caused  by  retarded  secretions,  and,  if  this  is  so,  to  perform  such  an 
operation  as  may  secure  good  drainage.  The  local  treatment  of  the  vaginitis 
itself  is  best  carried  out  by  the  application  of  iodin,  to  which  the  condition  readily 
yields. 

The  cicatricial  perineum  must  be  treated  by  a  plastic  operation,  in  which 


SPECIAL   GYNECOLOGIC   DISEASES  547 

the  scar-tissue  is  carefully  dissected  out.  It  is  best  to  make  a  transverse  incision 
at  the  middle  hne,  and  to  carry  out  the  dissection  with  scissors  suhcutaneoushj 
on  each  side.  This  avoids  the  removal  of  any  epithelial  tissue.  The  wound  is 
sewed  up  in  the  opposite  direction  of  the  incision.  In  this  way  a  funnel-shaped 
opening  is  given  to  the  introitus,  through  which  the  vaginal  secretions  can 
now  easily  drain  (see  page  646). 

The  wound  from  this  operation  must  be  sewed  up  with  great  care  as  to  ap- 
proximation, otherwise  there  is  more  than  ordinary  danger  of  sepsis  and  healing 
by  granulation,  which  may  result  in  a  new  scar  similar  to  that  which  was  dis- 
sected out. 

Treatment  of  the  vulva  depends  chiefly  on  securing  proper  vaginal  drainage. 
If  permanent  changes  have  taken  place  in  the  cutis,  ovarian  extract  is  indicated, 
and  is  sometimes  followed  by  very  satisfactory  results. 

Ectropion  of  the  urethral  mucous  membrane  is  best  treated  by  plastic  exci- 
sion, while  caruncles  may  be  removed  either  by  operation  or  by  the  use  of  the 
high-frequency  current.  This  last  method  of  treatment  is  especially  valuable  in 
the  recurrent  type  of  caruncle  (q.  v.). 

Irritabihty  of  the  urethra  due  to  stricture  yields  readily  to  dilatation.  Irri- 
tabihty  due  to  local  inflammation  of  the  urethral  or  vesical  mucous  membrane 
is  exceedingly  pertinacious  and  difficult  to  cure.  It  is  referred  to  in  greater  detail 
on  page  270. 

UTERINE  INSUFFICIENCY 

This  is  a  somewhat  vague  term,  used  to  designate  a  uterine  condition  in 
which  there  is  severe  menorrhagia  without  any  apparent  well-defined  anatomic 
cause  for  the  abnormal  bleeding.  Various  names  have  been  applied  to  this 
condition,  but  "uterine  insufficiency"  describes  it  best,  in  that  it  implies  an  ina- 
ability  of  the  uterine  musculature  to  terminate  properly  the  menstrual  flow  of 
blood.  We  meet  with  uterine  insufficiency  most  commonly  in  women  approach- 
ing the  menopause,  though  it  sometimes  occurs  in  comparatively  young  women. 
It  may  be  so  severe  and  persistent  as  to  be  regarded  as  a  definite  disease,  or  it 
may  occur  as  a  temporary  condition,  as  sometimes  happens,  for  example,  during 
the  establishment  of  the  menopause. 

With  regard  to  the  etiology  and  pathology  of  uterine  insufficiency  we  are 
very  much  in  the  dark.  It  was  formerly  quite  generally  supposed  to  be  the 
result  of  a  premature  arteriosclerosis  of  the  uterine  blood-vessels,  but  this  view 
has  little  acceptance  at  the  present  time.  One  investigator  (Theilhaber)  has 
advanced  the  interesting  theory  that  the  inability  of  the  uterine  musculature 
to  functionate  properly  is  due  to  a  disproportion  of  connective  tissue  over  mus- 
cular tissue  in  the  myometrium.  He  showed  that  as  the  menopause  is  ap- 
proached there  is  a  progressive  diminution  of  the  muscular  fibers  of  the  myo- 
metrium, with  a  corresponding  increase  of  connective  tissue.  This  change  may 
be  increased  by  successive  pregnancies.    If  the  increase  of  muscle  over  connective 


548  GYNECOLOGY 

tissue  is  abnormal  the  uterine  wall  may  lose  its  contractile  power  to  such  an  ex- 
tent that  it  becomes  insufficient  to  control  the  menstrual  flux.  The  theory  is 
logical,  and  probably  explains  to  some  extent  the  menorrhagias  seen  near  the 
menopause.  It  is,  however,  not  entirely  borne  out  by  experimental  evidence 
(Schickele). 

More  recent  theories  explain  uterine  insufficiency  on  the  ground  of  some 
aberration  of  the  ovarian  secretions.  A  discussion  of  this  subject  is  found  on 
page  45. 

Symptoms. — The  chief  sjaiiptom  of  uterine  insufficiency  is  excessive  or 
prolonged  menstruation,  usually  with  a  shortened  intermenstrual  period.  The 
blood  is  often  clotted.  Secondary  symptoms  resulting  from  anemia  and  exhaus- 
tion may  be  varied  and  numerous.  Prominent  among  these  are  nervous  dis- 
turbances, which  are  due  partly  to  the  constitutional  drain  from  loss  of  blood 
and  partly  to  mental  apprehension. 

Diagnosis. — In  order  to  make  a  diagnosis  of  uterine  insufficiency  it  is  neces- 
sary to  rule  out  absolutely  all  other  conditions  which  simulate  it.  These  are 
most  commonly  abnormal  gland  hypertrophy  of  the  endometrium,  cervical 
or  endometrial  polyps,  uterine  myomata,  and  cancer  either  of  the  body  or 
cervix.  Such  a  diagnosis,  as  a  rule,  should  be  made  under  an  anesthetic,  so 
that  a  careful  intra-uterine  examination  with  the  curet  and  placenta  forceps 
may  be  carried  out.  If  the  cervix  is  at  all  doubtful,  a  piece  is  removed.  The 
specimens  of  endometrial  and  cervical  tissues  are  placed  at  once  in  formalin  or 
alcohol  and  examined  by  a  competent  pathologist.  By  the  examination  under 
an  anesthetic  small  fibroids  may  be  more  easily  detected;  if  the  condition  is  due 
to  a  gland  hypertrophy  or  an  endometrial  polj^p,  the  removal  of  tissue  may 
serve  as  a  curative  measure;  while  if  cancer  is  present  the  patient's  life  may  be 
saved  by  a  timely  radical  operation. 

If  the  above-mentioned  conditions  can  be  ruled  out,  we  are  then  justified  in 
making  a  diagnosis  of  uterine  insufficienc^^  The  uterus  may  be  misplaced, 
and  it  may  be  larger  and  softer  than  normal.  On  the  other  hand,  it  is  some- 
times perfectly  normal  in  size  and  consistency. 

The  treatment  of  these  cases  is  either  palliative  or  radical.  Palliative 
measures  are  usually  to  be  tried  first  if  there  is  no  doubt  about  the  diagnosis, 
as  uterine  insufficiency  is  not  a  fatal  disease  and  time  may  be  taken  in  its  treat- 
ment. 

Cureting,  as  a  rule,  does  little  more  than  temporary  good,  if  it  does  that. 
The  usual  drugs,  such  as  ergot,  hydrastis,  hamamehs,  etc.,  are  practically  useless. 
Pituitrin  is  reported  to  be  of  some  value,  but  seems  to  be  less  efficacious  than  in 
the  functional  menorrhagias  of  youth. 

Vaporization  is  sometimes  used  in  the  treatment  of  the  so-called  hemorrhagic  metropathies, 
of  which  uterine  insufficiency  is  the  most  conspicuous  example.  The  method  employed  by 
Fuchs  is  as  foUows:  The  uterine  cavity  is  first  thoroughly  cureted.  An  insulating  tube  is  then 
introduced  to  protect  the  isthmus.     Steam  is  applied  to  the  cavity  of  the  uterus  at  a  tempera- 


SPECIAL    GYNECOLOGIC    DISEASES  549 

ture  of  115°  to  120°  F.  for  from  thirty  to  sixty  seconds.  This  method  is  especially  appHcable 
to  uterine  insufficiency  of  the  preclimacterium,  but  is  contra-indicated  in  all  inflammatory 
conditions  either  of  the  uterus  or  of  the  myometrium.  Fuchs  claims  a  cure  of  92  per  cent,  in 
the  treatment  of  71  cases. 

We  have  had  no  experience  with  this  method. 

The  most  efficacious  treatment  for  uterine  insufficiency  is  by  the  use  of 
radium.  A  full  discussion  of  the  treatment  is  given  in  the  section  on  Radium 
Therapy  in  Non-malignant  Conditions  {q.  v.). 

Many  times  it  is  necessary  to  resort  to  operative  measures.  If  the  uterus  is 
retroflexed  and  congested  an  operation  for  replacing  it  may  relieve  or  cure  the 
symptoms,  but  this  result  is  by  no  means  to  be  guaranteed,  and  the  patient 
should  understand  this  before  the  operation  is  performed.  If  palhative  measures 
fail,  and  the  patient  is  near  the  menopause,  supravaginal  hysterectomy  may  be 
resorted  to  with  a  practically  sure  prospect  for  cure.  The  results  of  the  opera- 
tion are  especially  good  in  restoring  the  patient  to  a  normal  equilibrium  when 
there  has  been  a  nervous  element  in  the  symptomatology.  A  decision  for  the 
operation  of  hysterectomy  in  uterine  insufficiency  is  governed  by  much  the  same 
factors  as  those  considered  in  the  Treatment  of  Chronic  Pelvic  Inflammation 
(see  page  212). 

Dr.  Howard  A.  Kelly  has  recommended  an  operation  which  he  calls  "hys- 
terotomy." This  consists  in  removing  the  endometrium  by  taking  out  a  wedge 
from  the  center  of  the  uterine  body.  It  is  doubtful  if  the  results  of  this  operation 
make  it  preferable  to  hysterectomy,  except  in  special  cases  based  on  senti- 
mental considerations. 

INFANTILISM   AND   STERILITY^ 

The  term  "sterihty"  is  somewhat  difficult  of  precise  scientific  definition.  It 
is  not  enough  to  say  that  sterility  imphes  an  inability  to  conceive,  for  it  may 
be  that  by  the  removal  of  certain  obstacles  the  individual  may  become  per- 
fectly capable  of  impregnation.  It  is  necessary  to  understand,  therefore,  that 
the  word  sterility  may  be  used  in  a  variety  of  senses,  for  which  a  number  of 
modifying  terms  have  been  suggested.  Absolute  sterility  is  a  condition  where 
impregnation  is  obviously  impossible,  as  in  certain  cases  of  defective  uterus  or 
ovaries,  or  in  congenital  absence  of  vagina.  The  expressions  "primary"  and 
"secondary  sterility"  are  frequently  used.  Primary  sterihty  denotes  that  the 
individual  does  not  conceive  under  normal  conditions  during  the  first  few  years 
of  married  life,  arbitrary  times  being  set  by  different  observers,  as  three  years 
(Kisch)  and  five  years  (Torkel  and  E.  Frankel).  Secondary  or  acquired  sterihty 
is  used  to  describe  the  individual  who  though  at  first  fruitful  or  capable  of 
child-bearing,  later  becomes  incapable  of  fertihzation. 

1  The  material  in  this  section  is  taken  from  an  article  by  the  author  published  in  the  Transactions 
of  the  American  Gynecological  Society  of  1913. 


,550  GYNECOLOGY 

Etiology. — The  causes  of  sterility  may  be  divided  broadly  into  those  that  are 
idiopathic  and  those  that  are  acquired.  The  chief  idiopathic  causes  of  sterility 
are  fetalism  and  infantilism  of  the  genital  organs.  Fetalism,  a  term  introduced 
by  Alfred  Hegar,  relates  to  a  faulty  or  arrested  development  that  takes  place 
in  intra-uterine  life,  and  is  represented  by  the  various  forms  of  uterus  didelphys 
or  the  failure  of  the  union  of  the  Miiherian  ducts,  and  by  conditions  of  aplasia, 
such  as  absence. of  the  vagina,  uterus,  ovaries,  or  tubes.  In  most  cases  of 
fetahsm  impregnation  is  obviously  impossible,  and  therapeutic  or  surgical 
measures  for  producing  fertihty  are  entirely  out  of  the  question.  Infantilism, 
on  the  other  hand,  as  the  term  will  be  used,  presupposes  that  the  individual  has 
been  born  with  a  full  equipment  of  genital  organs,  without  mechanical  obstruc- 
tion to  fetation,  but  that  during  childhood  an  arrest  in  development  takes 
place,  so  that  in  the  child-bearing  age  the  organs  retain  certain  characteristics 
-of  the  prepubescent  period.  Infantihsm  of  the  genitals  may  occur  as  the  only 
stigma  of  defective  development,  and  the  individual  may  be  otherwise  perfectly 
and  even  exceptionally  developed;  or  the  genital  infantilism  may  constitute 
only  an  incident  in  a  general  hypoplasia  manifested  in  other  parts  of  the  body. 
We  see,  therefore,  two  characteristic  types  of  sterile  women — one  the  large, 
full-blooded,  often  powerful-looking  individual,  with  tendency  to  f^-t  accumula- 
tion, and  the  other  the  meager,  unripe  old-maid  type.  In  the  woman  of  the 
first  class  there  is  usually  nothing  in  the  external  appearances  to  suggest  a  genital 
hypoplasia,  while  the  individual  of  the  latter  class  exhibits  numerous  easily 
recognizable  characteristics.  Among  the  famihar  marks  of  the  old-maid  type 
of  woman  are  the  long,  thin,  unbeautiful  neck;  the  long,  small  thorax;  the  weak 
flat  back,  with  its  spinal  curvature,  winged  scapulae,  and  lack  of  muscular  de- 
velopment; the  flat  pelvis,  the  poor  development  of  the  glutei  muscles;  the  narrow 
hips  and  slender  thighs,  and  the  underdeveloped  or  thin  pendulous  breasts.  In 
both  these  classes  of  women  the  nervous  system  is  extremely  sensitive  and  the 
nervous  equihbrium  unstable.  In  both  there  is  usuafly  some  menstrual  dis- 
turbances, most  commonly  in  the  form  of  severe  dysmenorrhea,  which  is  an 
important  factor  in  the  nervous  symptomatology. 

The  external  genitals  may  or  may  not  be  fully  developed,  but  in  the  old- 
maid  type  of  woman  they  are  often  meager,  the  labia  minora  being  pale  and  thin, 
and  the  labia  majora  flat  and  ill  formed.  In  such  cases  the  musculature  of  the 
perineum  is  often  defective,  and  occasionally  vaginal  prolapse  or  procidentia  of 
the  uterus  occurs. 

Causes  of  Infantilism. — The  causes  of  infantilism  are  somewhat  problematic. 
It  would  seem  as  if  hereditary  and  early  environmental  influences  might  be 
important  factors.  There  is  no  doubt  that  syphilis,  alcohoHsm,  epilepsy,  and 
insanity  of  ancestors,  as  well  as  race  degeneration  from  incest  or  consanguinity, 
are  responsible  for  a  certain  amount  of  infantihsm  in  the  offspring.  Premature 
■birth,  poor  nourishment  during  infancy,  early  diseases,  such  as  rickets,  tuber- 
culosis, chlorosis,  etc.,  are  often  found  in  the  histories  of  hypoplastic  individuals. 


SPECIAL   GYNECOLOGIC   DISEASES  551 

Many  cases  show  congenital  defects  in  the  circulatory  and  respiratory  organs, 
such  as  small  hearts,  narrow  and  thin-walled  vessels,  and  long,  narrow  chest 
walls,  with  insufficient  lung  capacity,  though  these  defects  are  often  regarded 
not  so  much  a  cause  of  the  genital  infantilism  as  a  manifestation  of  a 
general  constitutional  hypoplasia,  in  which  the  genital  defects  incidentally 
take  part. 

It  is  necessary  to  take  into  consideration  the  possible  relationship  of  the  other 
glands  of  internal  secretion,  such  as  the  adrenals,  the  thyroid,  the  hypophysis, 
and  the  thymus.  It  is  well  known  that  these  organs  all  have  an  intimate  relation- 
ship with  the  organs  of  generation,  and  that  mild  disturbances  of  the  harmony 
between  these  related  organs  of  internal  secretion  may  interfere  with  the  most 
important  function  of  the  ovary  and  its  germ-cells.  Diseases  of  the  various 
organs  of  internal  secretion  are  usually  attended  with  genital  atrophy  or  infan- 
tilism and  sterility.  Patients  suffering  from  hypophyseal  diseases,  such  as  acro- 
megaly and  giantism,  or  hypopituitarism,  are  amenorrheic  and  sterile.  Patients 
with  myxedema  are  usually  sterile  and  have  deficient  genitalia,  while  Graves' 
disease  is  often  attended  with  sterility  and  functional  disturbances  of  menstrua- 
tion. The  same  is  true  of  Addison's  disease.  This  branch  of  the  subject  of 
sterility  is  comparatively  new,  but  the  knowledge  which  is  rapidly  being  ac- 
quired of  the  physiology  and  chemistry  of  the  organs  of  internal  secretion  gives 
great  promise  of  shedding  hght  on  a  class  of  cases  which  has  hitherto  been  com- 
pletely baffling. 

The  question  of  the  influence  of  the  internal  glandular  secretions  on  the 
development  of  the  genitalia  is  treated  in  a  separate  section  (Part  I) . 

It  is  an  interesting  query  why  infantilism  is  more  common  in  women  than  it 
is  in  men.  It  may  be  said  that  the  sexual  apparatus  of  woman  is  so  much  more 
comphcated  than  that  of  man  that  the  chances  of  local  hypoplasia  are  very  much 
increased.  Hans  Bab  says,  "In  general  habit,  in  constitution,  and  in  general 
mentality  woman  is  half-way  between  man  and  child,  and  hence  a  certain 
amount  of  infantilism  may  be  regarded  as  physiologic."  There  is  unquestion- 
able biologic  basis  for  this  theory. 

In  considering  the  causes  of  sterility  from  infantilism  it  is  necessary  to 
reahze  that  there  is  a  wide  field  of  possibiHties,  any  one  of  which  may  con- 
ceivably be  sufficient  to  prevent  impregnation.  These  various  abnormalities 
may  occur  in  any  part  of  the  internal  or  external  genitals,  and  it  is  important  to 
discuss  them  in  detail. 

Ovaries. — The  ovaries  of  women  who  are  sterile  on  account  of  infantihsm 
may  be  entirely  normal,  or  they  may  present  certain  characteristics  typical  of 
the  hypoplastic  condition.  In  somewhat  rare  instances  there  is  an  incomplete 
descent  of  the  ovary,  which  may  be  retained  in  a  position  at  or  even  above  the 
brim  of  the  pelvis.  It  is  usually  associated  with  a  short  appendiculo-ovarian 
ligament,  which  may  have  the  effect  of  retro  verting  the  uterus.  Non-descent 
of  the  ovary,  however,  is  not  to  be  regarded  as  a  common  cause  of  sterihty,  and 


552  GYNECOLOGY 

whenever  it  occurs  there  are  usually  other  stigmata  of  developmental  defect 
sufficient  to  prevent  fetation. 

The  ovaries  in  infantilism  often  present  certain  characteristics  that  may  be 
of  special  significance.  They  may  be  very  smafi,  often  not  larger  than  a  hazel- 
nut. The  contour  instead  of  being  oval  is  often  elongated  or  spindle  shaped, 
while  in  other  instances  the  ovary,  while  retaining  its  normal  contour,  is  markedly 
flattened. 

Another  characteristic  frequently  seen  in  infantile  ovaries  is  the  dense 
whiteness  and  smoothness  of  the  surface.  This  is  due  to  a  marked  thickening 
of  the  albuginea  or  connective-tissue  cortex  of  the  organ.  Many  times  the 
ovaries  of  infantihsm  are  larger  than  normal,  due  to  the  tendency  to  atretic  fol- 
licle formation. 

If  these  hypoplastic  ovaries  be  examined  microscopically  it  will  often  be 
found  that  most  of  the  follicles  have  not  developed  beyond  the  primordial  state, 
and  that  there  is  a  marked  increase  in  connective  tissue,  as  manifested  by  the 
thickened  albuginea.  According  to  Kehrer,  this  lack  of  development  of  the  follicle 
apparatus  accounts  for  the  defective  function  of  the  ovaries  on  the  ground  of  the 
late  onset  of  menstruation,  the  frequency  of  amenorrhea  and  dysmenorrhea,  of 
sterility  and  failure  of  sexual  impulse,  vicarious  menstruation,  etc.- 

Very  theoretic  is  the  explanation  of  ovarian  deficiency  on  what  might  be 
called  mechanical  grounds,  by  which  an  attempt  is  made  to  show  that  the 
proper  ripening  and  bursting  of  the  foUicle  is  prevented  either  by  too  great  ex- 
ternal resistance  or  by  insufficient  internal  pressure. 

Ovaries  vary  greatly  in  size  and  in  the  number  of  follicles  in  different  indi- 
viduals, and  even  in  the  same  individual.  According  to  Waldeyer  and  Heyse, 
the  average  total  number  of  follicles  amounts  to  about  35,000.  Only  about  400 
of  these  follicles  ripen  during  the  thirty  years  of  menstrual  life,  hence  most  of 
them  become  atretic,  with  the  consequent  death  of  the  ovum  and  the  granulosa 
epithelium.  According  to  Strassman,  this  foUicle-atresia  represents  a  rudimen- 
tary state  of  development  and  takes  place  not  only  in  young  childhood  but  even 
in  fetal  life.  Certain  it  is  that  it  is  very  characteristic  of  the  ovaries  of  hypo- 
plastic genitalia,  in  which  the  follicle  atresia  seems  to  take  the  place  partially  or 
completely  of  the  normal  ripening  and  bursting.  The  cause  of  this  is  uncertain, 
but  may  be  explained  theoretically  with  a  certain  amount  of  reason.  The  com- 
pHcated  process  of  ripening  and  bursting  of  a  normal  mature  follicle  presupposes 
rather  a  delicate  balance  between  the  internal  pressure  of  the  follicle  and  the 
resisting  power  of  the  surrounding  envelope  of  the  ovary.  As  has  been  pointed 
out,  the  ovaries  of  sterile  women  often  show  an  albuginea  (or  connective-tissue 
cortex)  which  is  thicker  and  denser  than  normal.  It  is  also  seen  that  the  cells 
of  the  germinal  epithelium  in  infantile  ovaries  are  higher  and  larger  than  those 
of  the  normal  ovary.  Hence  it  is  conceivable  that  the  folhcle  meets  with  too 
great  a  resistance  to  reach  full  maturity  and  discharge  of  the  ovum.  It  is  pos- 
sible, too,  as  Hans  Bab  suggests,  that  the  internal  pressure  of  the  folHcle  may  be 


SPECIAL   GYNECOLOGIC   DISEASES  553 

deficient  on  account  of  incomplete  congestion,  as  is  manifested  by  the  scanty  or 
infrequent  menstruation  which  often  characterizes  these  cases.  It  is  not  un- 
common to  find  no  traces  whatever  of  corpus  luteum  formation  in  these  ovaries. 

Tubes. — Although  we  know  that  the  tubes  play  a  most  important  role  in 
the  acquired  sterihty  that  results  from  gonorrhea  and  tuberculosis,  we  do  not 
always  reahze  that  they,  too,  may  take  part  in  the  genital  hypoplasia  and  be 
the  means  of  preventing  conception.  Some  of  the  theories  regarding  infantihsm 
of  the  tubes  are  worthy  of  note.  W.  A.  Freund,  to  whom  we  are  indebted  for  the 
foundation  of  our  present  knowledge  of  the  subject  of  infantihsm,  called  atten- 
tion to  the  fact  that  at  birth  the  tubes  are  markedly  twisted  in  a  spiral  form, 
especially  at  the  uterine  ends.  We  are  familiar  wdth  this  appearance  in  cases  of 
chronic  salpingitis,  and  it  was  at  first  objected  that  what  Freund  had  inter- 
preted as  a  congenital  twisting  was,  in  fact,  the  result  of  a  fetal  pelvic  inflamma- 
tion. This  abnormality  has  been  found  so  commonly,  however,  in  cases  of 
genital  hypoplasia  that  it  is  now  regarded  as  a  stigma  of  infantihsm,  and  it  is 
thought  that  it  may  in  some  way  prevent  conception.  It  is  supposed  also  that 
this  congenital  twisting  of  the  tube  may  account  for  those  unexplained  cases 
of  extra-uterine  pregnancy  which  occasionally  occur  in  women  who  have  long 
been  sterile. 

Bumm  has  called  attention  to  the  fact  that  the  development  of  the  fimbriated 
end  of  the  tube  may  be  of  great  importance  in  receiving  the  egg  on  its  passage 
from  the  ovary,  and  shows  how  in  normal  cases  the  fimbriae  exhibit  a  beautifully 
delicate  and  profuse  structure,  while  in  others  it  is  scanty  and  meager.  When 
one  considers  the  frequency  with  which  impregnation  takes  place  after  resection 
of  the  tubes,  it  must  be  admitted  that  the  presence  of  the  fimbrise  is  not  neces- 
sarily essential  to  impregnation,  though  it  is  probable  that  defective  develop- 
ment of  them  acts  as  a  partial  preventive  of  conception. 

Other  structures  of  the  tube  which  may  be  affected  by  infantihsm  are  the 
musculature,  the  labyrinth,  and  the  ciha.  The  arrangement  of  the  muscular 
structure  of  the  tubes  makes  ^it  probable  that  a  peristaltic  action  takes  place 
which  is  important  in  passing  on  the  germ-cells,  and  that  incomplete  action  due 
to  congenital  weakness  may  result  in  sterility  or  extra-uterine  pregnancy. 
The  labyrinth  and  the  ciha  are  of  very  great  importance  in  a  sterility  which  is 
due  to  inflammatory  processes,  and  there  is  no  reason  to  doubt  that  an  incom- 
plete development  of  these  delicate  structures  of  the  tube  may  also  have  a  con- 
siderable influence  in  preventing  fertihty. 

Uterus.— In  making  a  diagnosis  of  genital  infantilism  one  is  very  largely 
guided  by  the  examination  of  the  uterus,  and  it  is  to  this  organ  that  surgical  or 
manipulative  treatment  is  usually  directed.  There  is  no  doubt  that  develop- 
mental abnormalities  in  the  position  of  the  uterus  often  cause  sterility,  as  is 
proved  by  the  frequency  with  which  the  condition  is  cured  by  surgical  cor- 
rection. 

The  infantile  uterus  is  the  keynote  to  genital  hypoplasia  and  is  easily  recog- 


554  GYNECOLOGY 

nizable.  It  may  appear  in  two  forms.  In  the  first  the  entire  uterus,  normal  in 
its  proportions  of  the  body  and  neck,  is  simply  a  miniature  of  the  fully  developed 
organ,  and  is  termed  a  ''pubescent"  or  "dwarf"  uterus.  In  the  sec(3nd,  and  far 
more  common  form,  there  is  a  disproportion  between  the  body  and  neck.  Where- 
as normally  the  body  of  the  uterus  is  about  7  cm.  long  and  the  cervix  3  cm.,  in 
the  infantile  uterus  the  conditions  are  reversed,  the  cervix  being  longer  than  the 
body.  There  is  usually  also  an  abnormal  relationship  in  position  between  the 
body  and  the  neck  in  the  form  of  a  sharp  anteflexion  or  retroflexion.  The  long 
cervix  is  slender  and  conical  and  'points  in  the  axis  of  the  vagina,  whether  the 
body  be  ante-  or  retroflexed.  If  there  is  no  abnormal  flexion,  and  the  body  is 
in  position,  the  cervix  points  in  the  proper  direction,  but  is  so  long  that  it  im- 
pinges on  the  posterior  wall  of  the  vagina  and  gives  one  the  impression  of  being 
far  back  in  the  sacrum. 

Of  the  conditions  of  retroflexion  and  anteflexion,  that  of  anteflexion  is  much 
more  common,  and  occurs  so  frequently  that  a  diagnosis  of  its  presence  can 
often  be  made  from  the  history  of  dysmenorrhea  and  sterility  with  which  it  is 
usually  associated. 

Do  developmental  flexions  of  the  uterus  cause  sterility?  Up  to  the  present 
time  no  very  satisfactory  answer  to  this  question  has  been  evolved.  It  is  in- 
conceivable that  the  bend  in  the  uterus  should  act  as  an  actual  mechanical 
obstruction  to  the  passage  of  the  spermatozoon  by  narrowing  the  canal.  In 
most  cases  the  canal  is  dilated  with  great  ease,  the  only  difficulty  being  in  those 
instances  where  a  cicatricial  band  forms  near  the  point  of  flexion.  The  old-time 
theory  of  obstruction  is  explained  away  by  the  observations  of  uteri  in  swine, 
sheep,  and  dogs,  in  which  the  sharpest  physiologic  flexions  cause  no  hindrance 
to  the  spermatozoa. 

There  is  little  doubt  that  the  abnormal  relationship  that  exists  between  the 
cervix  and  vagina  in  all  cases  of  forward  or  backward  flexion  has  an  important 
influence  in  preventing  sterility.  We  have  seen  that  the  cervix  points  in  the 
direction  of  the  long  axis  of  the  vagina  instead  of  at  right  angles  to  it.  It 
would  at  first  seem  as  if  the  former  were  a  more  favorable  position  for  the  recep- 
tion of  the  spermatozoon  after  ejaculation,  and,  in  fact,  anatomists  not  so  very 
long  ago  believed  it  to  be  the  normal  position  of  the  cervix.  It  has  been  pointed 
out,  however,  that  the  pouch  which  lies  behind  the  vaginal  portion  of  the  cervix 
plays  an  important  part  in  the  retention  of  the  semen,  and  has  aptly  been 
termed  by  Biegel  the  receptaculum  seminis.  Under  normal  anatomic  conditions 
the  cervix  points  directly  into  this  receptacle,  and  after  coition  dips  into  the  pool 
of  semen  there  retained.  In  this  way  the  passage  of  the  spermatozoa  into  the 
cervical  canal  is  greatly  favored.  In  nearly  all  cases  of  hypoplasia  this  proper 
relationship  between  cervix  and  vagina  is  disturbed.  If  the  uterus  is  flexed 
either  forward  or  backward  the  cervix  points  directly  away  from  the  recep- 
taculum. When  there  is  no  flexion  the  cervix  is  often  so  long  that  it  impinges 
strongly  against  the  posterior  wall  and  the  receptaculum  is  obUterated.     Ab- 


SPECIAL    GYNECOLOGIC    DISEASES  555 

normal  shortness  of  the  vaginal  wall  may  bring  about  like  conditions,  for  if  the 
anterior  wall  is  too  short  the  cervix  is  pulled  forward,  and  if  the  posterior  wall  is 
too  short  the  receptaculum  is  obliterated. 

It  has  been  mentioned  above  that  in  many  cases  of  flexion  due  to  hypoplasia 
there  exists  a  cicatricial  band  in  the  cervical  canal  corresponding  to  the  point  of 
angulation,  usually  at  the  level  of  the  internal  os.  This  band  offers  a  distinct 
resistance  to  the  passage  of  sound  or  dilator,  and  gives  an  impression  similar 
to  that  given  by  a  urethral  stricture.  Bumm  has  styled  this  condition  "callous 
stenosis"  of  the  cervix,  and  is  of  the  opinion  that  it  is  an  important  factor  in  the 
prevention  of  conception.  The  origin  of  this  cicatricial  band  is  not  known. 
Whether  it  is  a  result  of  the  long-standing  flexion,  or  whether  it  existed  primarily 
and  was  instrumental  in  causing  the  flexion,  is  a  matter  of  speculation.  The 
existence  of  abnormal  connective  tissue  in  the  infantile  uterus  is  not  surprising 
in  view  of  the  fact  that  in  the  uterus  before  puberty  there  is  a  preponderant 
proportion  of  connective  tissue  to  musculature  (Theilhaber) . 

It  is  also  a  matter  of  speculation  as  to  how  this  cicatricial  band  serves  to 
prevent  conception.  It  may  alter  the  reaction  of  the  cervical  secretions  by  in- 
terference with  its  circulation,  or  it  may- favor  the  formation  of  a  cervical  mucous 
plug  which  obstructs  the  entrance  of  spermatozoa.  Moreover,  it  is  observed 
that  when  this  callous  stenosis  is  present  the  cervix  has  a  tendency  to  be  stiff 
and  unyielding.  Sims  many  years  ago  called  attention  to  the  fact  that  the 
structure  of  the  cervix,  as  well  as  its  form  and  position,  is  of  much  significance 
for  the  reception  of  the  spermatozoon,  and  there  is  no  doubt  that  a  cervix  lack- 
ing in  normal  mobility  is  unfavorable  to  fertility.  This  is  especially  important, 
in  view  of  the  fact  that  the  normal  cervix  has  to  a  certain  extent  the  function 
of  aspirating  the  semen  from  the  vagina  (Rohleder).  E.  Frankel  has  pointed 
out  that  the  prognosis  for  the  cure  of  sterility  where  callous  stenosis  is  present  is 
especially  bad. 

The  term  "effluvium  seminis"  is  used  to  describe  the  escape  of  semen  from 
the  vagina  following  coitus,  and  is  thought  by  some  to  be  an  important  cause  of 
sterility.  This  condition  may  be  brought  about  by  lacerations  and  prolapse  of 
the  vaginal  walls  from  childbirth,  but  it  may  also  be  the  result  of  hypoplastic 
defects  in  the  vaginal  wall.  Bumm  has  repeatedly  shown  in  cases  of  short  ante- 
rior vaginal  wall  the  absence  of  spermatozoa  in  the  vaginal  or  cervical  secretion 
shortly  after  coitus.  It  is  said  that  some  women  have  the  power  of  voluntarily 
pressing  out  the  semen  and  thus  preventing  conception  for  long  periods  of  time. 
Bumm  says:  "Although  only  one  spermatozoon  is  necessary  for  fertilization, 
nevertheless  there  is  little  chance  of  a  meeting  of  the  egg  and  this  one,  if  out  of 
the  millions  of  spermatozoa  deposited  at  each  coition  at  least  thousands  do  not 
reach  the  internal  genitalia." 

Natanson  and  Konigstein  have  investigated  the  significance  of  the  escape  of  semen  from 
the  vagina  as  a  cause  of  sterihty  in  26  sterile  women  who  complained  of  this  complication. 
They  examined  the  uterine  and  vaginal  secretions  for  spermatozoa  from  three  to  sixty  hours 


556  GYNECOLOGY 

post  coitiim.  Of  the  26  cases,  13  had  uterine  misplacements,  11  were  hypoplastic,  and  2  had 
cervical  catarrh  without  anatomic  changes  of  the  uterus.  Twenty-two  of  the  women  had 
primary,  and  4  had  secondary,  sterihty.  In  38.5  per  cent,  spermatozoa  were  not  found  in  the 
uterus,  and  in  some  of  these  they  were  not  found  in  the  vagina.  Hence  it  is  Ukely  that  the 
man  was  at  fault  in  some  of  these  cases.  Spermatozoa  were  found  in  the  uterine  and  vaginal 
secretions  in  6  out  of  the  13  misplacement  cases,  in  9  out  of  the  11  hypoplastic  cases,  and  in  1  of 
the  cervical  catarrh  cases.  Inasmuch  as  spermatozoa  were  found  in  large  numbers  in  the 
uterine  secretions  of  61.6  per  cent,  of  these  cases,  the  writers  conclude  that  the  symptom  of 
effluvium  seminis  cannot  be  regarded  as  an  adequate  cause  for  sterihty. 

Although  effluvium  seminis  may  prevent  conception  to  a  certain  extent, 
its  effect  must  be  only  relative,  as  is  proved  by  the  frequency  with  which  im- 
pregnation takes  place  without  introition. 

Causes  of  Acquired  Sterility. — Gonorrhea. — Of  the  acquired  causes  of  sterility, 
gonorrhea  is  by  far  the  most  important,  especially  when  one  considers  the  light- 
ing effect  the  disease  has  on  the  procreative  powers  of  man  as  well  as  of  woman. 

In  woman  gonorrhea  most  commonly  prevents  fertility  by  sealing  the  ends 
of  the  Fallopian  tubes,  or  by  so  injuring  the  mucous  membrane  of  the  tubes  as 
to  destroy  their  function  as  oviducts.  This  injury  consists  in  a  gluing  together 
of  the  tips  of  the  dehcate  rugse  of  the  tubal  mucous  membrane,  so  that  the 
germ-cell,  instead  of  finding  a  free  passage  through  the  tube,  encounters  a  laby- 
rinth of  blind  pockets.  It  is  probable,  too,  that  in  this  process  there  is  a  more  or 
less  permanent  destruction  of  the  ciha  which  clothe  the  tubal  epithehum  and 
which  are  thought  to  aid  in  the  transference  of  the  germ-cell. 

Gonorrheal  infection  of  the  adnexa  has  been  differently  estimated  as  the 
cause  of  sterility  in  women  in  proportions  varying  from  8  to  59  per  cent. 
Sanger's  figures,  showing  33  per  cent.,  are  probably  near  the  truth. 

Gonorrhea  limits  fertility  also  by  infection  of  the  cervical  mucous  mem- 
brane, chronic  endocervicitis  being  a  frequent  cause  for  primary  sterility.  This 
condition  is,  however,  less  serious  than  when  the  adnexa  are  involved.  Endo- 
cervicitis may  also  be  the  cause  of  secondary  sterility,  for  it  not  infrequently 
happens  that  a  gonorrhea  of  the  cervix  acquired  after  impregnation  ascends  to 
the  tubes  postpartum,  and  thus  causes  a  permanent  secondary  sterility.  This 
process  is  the  chief  factor  in  one-child  sterility.  The  part  played  by  man  in 
sterile  marriages  has  of  late  received  much  attention,  and  he  has  been  found 
at  fault  in  a  far  greater  number  of  cases  than  was  formerly  supposed.  The  cause 
of  sterility  in  man  outside  of  impotency  is  commonly  due  to  gonorrheal  disease 
of  the  epididymis,  vasa  deferentia,  or  the  seminal  vesicles.  The  conditions 
found  are  azoospermia,  due  to  occlusion  of  the  vasa  deferentia  from  a  double 
epididymitis;  necrospermia,  in  which  the  spermatozoa  are  killed  on  account  of 
pathologic  changes  in  the  seminal  vesicles  and  prostate;  aspermatism,  due  to 
stricture.  Lier  and  Asher  found  that  70  per  cent,  of  sterility  in  man  is  due  to 
gonorrheal  changes,  and  in  comparing  the  relative  responsibility  of  man  and 
woman  in  sterile  marriages  they  estimated  that  of  man  at  about  40  per  cent, 
and  that  of  woman  at  about  60  per  cent.    The  actual  moral  responsibihty  of  man, 


SPECIAL   GYNECOLOGIC    DISEASES  557 

however,  is  considerably  greater  than  appears  in  these  figures,  because  a  very 
large  percentage  of  the  gonorrhea  in  married  women  has  been  transmitted  from 
husband  to  wife. 

Puerperal  Sepsis. — It  is  'very  difficult  to  compare  the  effects  of  gonorrheal 
infections  with  those  of  puerperal  sepsis.  Puerperal  sepsis  is  itself  frequently 
the  result  of  gonorrheal  infection,  so  that  in  such  cases  the  cause  and  effect  are 
essentially  gonorrheal.  Where  the  infection  is  entirely  puerperal  it  is  probable 
that  permanent  damage  is  less  than  that  wrought  by  gonorrhea.  Puerperal 
infections  are  more  apt  to  invade  the  pelvis  through  the  lymph-channels  of  the 
uterus  and  parametrium.  Thus  it  is  that  the  tubes  are  attacked  from  the 
outside.  Even  when  puerperal  sepsis  passes  into  the  tubes  through  the  uterine 
ostia  there  is  far  less  damage  to  the  tubal  mucosa  than  in  gonorrheal  salpingitis. 
Microscopically,  the  pus  is  seen  to  be  lying  on  the  surface  instead  of  invading 
the  submucosa.  There  is  not  the  plastic  exudation  and  gluing  of  the  rugae 
that  is  seen  in  gonorrheal  salpingitis,  and  it  is  possible  thus  sometimes  to  make 
a  microscopic  diagnosis  between  the  two  forms  of  infection. 

Endocervicitis  not  gonorrheal  in  origin  is  a  condition  to  be  reckoned  with  in 
treating  sterility,  and  one  which  is  more  readily  susceptible  of  cure  than  are  most 
of  the  other  causes.  It  is  manifested  by  a  hypersecretion  of  the  glands  of  the 
cervical  mucous  membrane,  so  that  the  cervix  is  filled  continually  with  a  thick 
plug  of  mucus  which  acts  as  a  complete  mechanical  obstruction  to  the  passage 
of  the  spermatozoon.  In  some  cases  the  reaction  of  the  cervical  secretion,  which 
is  normally  alkaline,  becomes  acid,  and  hence  becomes  a  medium  in  which  it  is 
impossible  for  the  sperm  cell  to  live. 

This  form  of  endocervicitis  may  be  due  to  ectropion  and  irritation  of  the 
cervical  mucous  membrane  following  laceration  of  the  cervix,  under  which  cir- 
cumstances, according  to  Schauta,  it  may  be  a  sufficient  cause  for  sterility. 
On  the  other  hand,  it  is  often  seen  in  nulliparous  uteri  even  in  virgins.  It  is 
often  associated  with  hypoplastic  uteri,  in  which  case  it  may  be  induced  by  a 
callous  stenosis  of  the  internal  os. 

That  this  mucous  hypersecretion  is  a  definite  etiologic  factor  in  sterility  is 
entirely  proved  by  the  frequency  with  which  a  simple  removal  of  the  plug  by 
a  cureting  or  local  treatment  of  the  cervix  is  followed  by  fertility. 

Endometritis. — When  we  come  to  infections  of  the  endometrium  with  refer- 
ence to  sterility  it  must  be  admitted  that  our  knowledge  is  very  vague.  We 
read  much  in  the  text-books  of  the  symptoms  and  treatment  of  acute  gonor- 
rheal endometritis  and  the  baleful  results  of  chronic  endometritis  as  a  result 
of  the  same  disease.  Nevertheless,  we  find  infrequent  microscopic  evidence  of 
true  endometritis,  acute  or  chronic,  even  in  cases  of  active  gonorrhea  of  the  ad- 
nexa.  It  is  evident  that  the  gonococcus  has  little  liking  for  the  endometrium, 
and  passes  to  the  more  congenial  tubal  mucous  membrane  as  rapidly  as  possible. 
Infectious  endometritis,  both  acute  and  chronic,  is  much  more  commonly  the 
result  of  puerperal  sepsis.     It  is  doubtful  if  endometritis  from  any  cause  (ex- 


558  GYNECOLOGY 

cepting  possibly  tuberculosis)  plays  an  important  part  in  preventing  conception, 
though  it  is  probable  that  the  chronic  interstitial  endometritis  that  occasionally 
follows  puerperal  or  gonorrheal  sepsis  may  encourage  spontaneous  abortion  by 
offering  a  poor  soil  for  the  nourishment  of  the  ovum. 

Genital  tuberculosis  is  nearly  always  attended  with  sterility.  The  tubes 
become  involved  in  adhesions  and  become  closed  in  the  same  way  as  in  a  gonor- 
rheal infection.  If  the  endosalpinx  is  involved,  the  disease  entirely  obliterates 
the  tubal  canal  and  frequently  invades  the  endometrium  and  myometrium  from 
above.     Early  genital  tuberculosis  often  causes  complete  amenorrhea. 

Cystic  Degeneration. — Kossman  thinks  that  small  cystic  degeneration  of  the 
ovaries  causes  sterility.  It  is  not  likely  that  cystic  degeneration  is  itself  a  cause 
of  sterility,  but  rather  merely  an  associated  condition.  We  have  already  seen 
how  it  may  be  the  result  either  of  too  great  resistance  on  the  part  of  the  albu- 
ginea  or  of  a  deficient  internal  pressure  in  cases  of  hypoplasia.  Cystic  degenera- 
tion is  also  common  in  pelvic  inflammatory  cases,  but  it  is  undoubtedly  of  entirely- 
secondary  importance  as  regards  sterility.  As  a  result  of  the  investigations  of 
Schiekele  and  others  cystic  degeneration  of  the  ovaries  is  no  longer  regarded  as 
an  essential  disease. 

Acquired  Misplacements  of  the  Uterus. — It  has  already  been  pointed  out  that 
congenital  or  developmental  misplacement  may  be  an  important  factor  in 
sterility.  Acquired  malposition  may  also  prevent  or  Hmit  fertihty.  There  is 
no  doubt  that  women  with  acquired  retroversion-flexion  are  in  a  large  percentage 
of  cases  sterile.  That  the  malposition  of  the  uterus  is  the  cause  of  the  sterility 
is  shown  sufficiently  well  by  the  frequency  with  which  these  patients  become 
pregnant  after  restoration  of  the  uterus  to  its  normal  position.  In  acquired  retro- 
version conception  is  probably  prevented  in  the  same  way  as  in  hypoplastic  mal- 
positions, not  by  mechanical  obstruction,  but  by  the  dislocation  of  the  cervix, 
by  which  it  no  longer  properly  dips  into  the  receptaculum  seminis. 

Relaxation  of  the  vaginal  walls  is  sometimes  regarded  as  a  cause  of  sterility.. 
It  is  doubtful,  however,  if  this  cause  is  a  frequent  one,  for  it  is  surprising  occa- 
sionally to  find  women  pregnant  who  have  very  marked  prolapse,  sometimes 
amounting  to  a  complete  procidentia.  If  relaxation  of  the  vagina  does  prevent 
conception,  it  is  possible  that  it  is  due  to  the  inabihty  of  the  semen  to  remain  in 
the  vagina,  with  consequent  effluvium. 

Tumors. — The  relation  of  tumors  to  conception  may  be  important.  Tumors 
of  the  external  genitals,  like  cysts  of  Bartholin's  glands,  vaginal  cysts,  fibromas 
of  the  vulva  or  vagina,  advanced  carcinoma  or  sarcoma  of  the  cervix  or  vagina, 
may  prevent  proper  coition.  Carcinoma  in  the  early  stages  does  not  necessarily 
cause  sterility,  for  instances  of  cancer  associated  with  pregnancy  are  occasionally 
observed,  and  would  be  seen  oftener  if  cancer  did  not  usually  occur  later  than  the 
child-bearing  period. 

Women  with  double  ovarian  tumors  are  usually  sterile,  but  unilateral  cysts 
are  no  prevention  to  conception.     Women  with  dermoid  cysts  of  the  ovary 


SPECIAL    GYNECOLOGIC   DISEASES  559 

are  frequently  sterile,  but  they  are  very  apt  to  have  stigmata  of  hypoplasia  in 
other  parts  of  the  genital  apparatus. 

The  relationship  of  uterine  myomas  to  sterility  is  a  subject  that  has  created 
a  great  amount  of  speculation  and  argument.  That  fibroids  should  act  as  a 
hindrance  to  fertility  is  not  surprising  when  one  considers  the  frequent  com- 
plication of  diseased  adnexa,  the  deformities  of  the  uterine  canal,  the  atrophic 
and  hypertrophic  changes  in  the  endometrium,  the  profuse  menstruation,  and 
other  abnormal  conditions  which  the  presence  of  myomas  may  bring  about. 
These  are  obvious  mechanical  hindrances  to  impregnation,  and  might  readily 
act  to  cause  a  secondary  sterility. 

This  explanation,  however,  does  not  account  for  the  primary  sterility  which 
it  is  claimed  characterizes  many  myomatous  women  before  the  fibroids  grow  to 
a  size  sufiicient  to  act  as  a  mechanical  hindrance  to  conception.  Some  authors 
believe  that  there  is  an  inherent  constitutional  cause  for  the  limited  fertility 
of  the  fibroid  uterus.  Abraham  Froell  says  in  his  work  on  the  subject,  "There 
exists  an  unknown  connection  between  the  physiologic  functions  of  the  uterus 
and  myoma  formation.  Myomatous  women  have  menstruated  at  an  earlier 
age  than  the  average,  and,  conversely,  girls  who  begin  to  menstruate  early  are 
more  likely  than  others  to  develop  myomas  in  later  life.  A  late  menopause  is 
the  rule  in  women  who  have  myomas."  The  author  is  of  the  opinion  that  the 
myomatous  constitution  limHs  and,  in  some  instances,  prohibits  fertility. 

x-Ray. — The  influence  of  the  rc-ray  on  fertility  is  a  matter  of  considerable 
importance  at  the  present  day,  especially  in  view  of  its  employment  in  the  treat- 
ment of  uterine  myomas,  which  in  some  quarters  is  being  so  urgently  recom- 
mended. There  is  now  no  doubt  that  the  x-ray  permanently  destroys  the  follicles 
of  the  ovary.  M.  Frankel  has  shown  that  the  ovaries  of  women  who  have 
been  treated  by  the  x-ray  show  marked  atrophy  of  the  Graafian  and  ripening 
follicles  as  well  as  a  scarcity  of  primordial  follicles. 

Reifferscheid  has  shown  by  animal  experimentation  that  there  is  no  pos- 
sible regeneration  of  a  folhcle  that  has  once  been  injured  by  the  influence  of  the 
x-ray.  He  also  found  that  the  epithelium  of  the  oviducts  undergoes  severe 
injury  when  exposed  to  the  rays.  From  these  observations  and  from  those  of 
many  others  it  is  estabhshed  that  the  x-ray  may  render  an  individual  com- 
pletely and  irreparably  sterile. 

It  has  been  noticed  by  some  observers  that  in  certain  cases  following  pelvic 
treatment  by  the  rays  there  is  a  temporary  period  of  amenorrhea,  followed  in 
several  months  by  a  re-establishment  of  the  normal  menses.  This  is  explained 
by  the  fact  that  x-ray  treatment  is  given  only  long  enough  to.  destroy  the  riper 
follicles,  and  that  it  is  not  continued  a  sufficient  length  of  time  to  injure  the 
primordial  follicles,  which  are  somewhat  more  resistant  to  the  ray.  In  the 
course  of  time  these  follicles  develop  and  ripen,  with  consequent  resumption  of 
the  menses.  It  is,  however,  possible  with  sufficient  dosage  to  injure  all  the 
follicles,  and  thus  completely  to  destroy  the  function  of  the  ovaries. 


560  GYNECOLOGY 

Miscellaneous  Causes. — Under  the  wasting  influence  of  some  diseases  the 
uterus  may  undergo  certain  atrophic  changes  and  thus  become  sterile.  The 
constitutional  diseases  which  may  induce  sterility  are  chlorosis,  tuberculosis, 
diabetes,  leukemia.  Graves'  disease,  Addison's  disease,  nephritis,  etc.  Of  these, 
tuberculosis  of  the  lungs  and  Graves'  disease  most  commonly  cause  trophic 
changes  in  the  genitalia. 

Diseases  of  the  hypophysis  exert  a  very  distinct  influence  on  the  genitaha, 
with  atrophy  of  the  ovaries,  amenorrhea,  sterility,  and  lack  of  secondary  sexual 
characters.  Mention  is  made  elsewhere  of  the  relationship  between  hypophyseal 
disease  and  the  pelvic  organs. 

Changes  in  the  germ-cells  of  the  ovaries  with  consequent  sterihty  are  said 
to  take  place  in  the  chronic  poisoning  of  morphin,  arsenic,  alcohol,  phosphorus, 
and  lead.  Leppich,  in  the  study  of  100  alcoholics,  found  28.3  per  cent,  of  them 
unfruitful. 

There  is  a  certain  relationship  between  adiposity  and  hypoplasia  of  the 
sexual  organs.  It  is  commonl}^  supposed  that  adiposity  tends  to  follow  badly 
functionating  sexual  glands,  as  in  amenorrheic  girls,  castrated  individuals,  and 
women  at  the  climacteric,  though  in  the  last-named  cases  the  idea  has  been 
greatly  exaggerated.  Conditions  described  as  infantilism,  hypopituitarism, 
eunuchoidism,  hypoth3^roidism,  disgenitalism,  dystrophia  adiposogenitalis,  etc., 
are  all  frequently  attended  by  fat  deposit  and  sexual  underdevelopment.  Con- 
versely, it  is  stated  by  Kirsch,  Mliller,  and  Horrocks  that  overnourishecl  women 
show  diminished  fertihty.  This,  however,  is  not  a  constant  rule,  for  occa- 
sionally fat  women  are  extremely  fertile.  One  writer  observes  that  whereas 
in  thin  women  1  out  of  every  10  is  sterile,  in  fat  women  an  average  of  4  out 
of  10  do  not  conceive.  It  seems  very  doubtful  if  the  ordinary  acquisition  of  fat 
in  a  woman  whose  genitalia  are  sound  would  hmit  her  fertility.  It  is  possible 
that  where  fat  deposit  and  sterility  are  found  associated  the  fat  is  a  manifestation 
of  an  ovarian  deficiency. 

The  protective  sterility  which  women  normally  undergo  during  lactation 
occasionally  becomes  permanent.  During  lactation  the  uterus  and  ovaries 
become  actually  atrophied  and  cease  to  functionate.  Cases  have  been  reported 
where  on  account  of  overlactation  the  uterus  has  become  permanently  atro- 
phied. This  doubtless  accounts  for  the  premature  senile  atrophy  of  the  external 
genitalia  that  one  occasionally  sees  in  women  of  the  poorer  classes  who  have  been 
fertile  earlier  in  life. 

Cases  have  been  reported  of  permanent  atrophy  of  the  uterus  and  amenor- 
rhea after  an  overzealous  cureting  operation. 

After  all  has  been  said  concerning  the  pathology  of  sterility,  there  remains 
a  very  large  percentage  of  marital  fruitlessness  which  is  referable  to  the  Mal- 
thusian  doctrine  and  is  the  result  of  preventive  measures.  Engelman,  in  a  study 
of  social  conditions  in  the  United  States,  estimated  that  only  12  per  cent,  of 
apparent  sterility  is  due  to  disease.     He  found  that  in  the  beginning  of  the 


SPECIAL   GYNECOLOGIC    DISEASES  561 

nineteenth  century  in  this  country  the  average  birth-rate  for  each  marriage  was 
5  children,  while  at  the  end  of  the  century  it  was  between  1  and  2.  Absence  of 
orgasm  and  libido-sexualis  plays  a  certain  part  in  sterihty.  Although  some 
women  who  experience  neither  of  these  sensations  are  fertile,  nevertheless 
frigidity  is  especially  common  in  sterile  individuals.  Matthews  Duncan,  in  an 
examination  of  191  sterile  women,  found  that  39  were  without  libido  and  62 
did  not  experience  orgasm.  Kisch,  in  an  examination  of  69  sterile  women, 
found  that  26  derived  no  pleasure  from  coitus.  Neumann  finds  that  in  most 
women  who  lack  sexual  sensibility  some  hypodevelopment  or  pathologic  dis- 
turbance of  the  genital  organs  can  be  found. 

Vaginismus  is  an  occasional  cause  of  sterility. 

There  are  some  cases  where  sterility  cannot  be  accounted  for  by  any  physical 
defect  on  the  part  of  either  husband  or  wife.  In  cases  of  this  kind  Mayerhofer 
has  advanced  the  interesting  theory  that  the  penetrative  power  of  the  spermat- 
ozoa of  a  given  individual  may  be  greater  with  some  women  than  it  is  with 
others.  The  most  famous  example  of  this  theory  is  that  of  Napoleon  and  the 
Empress  Josephine.  Josephine  had  two  children  by  her  first  marriage.  The 
marriage  with  Napoleon  was  fruitless,  but  Napoleon  in  his  second  marriage  with 
Marie  Louise  had  a  son,  the  Herzog  von  Reichstadt. 

Consanguinity  hmits  fertility.  According  to  the  figures  of  Golherts,  from 
32  to  33  per  cent,  of  consanguineous  marriages  are  sterile,  as  against  the  average 
sterility  of  8  to  15  per  cent. 

The  mingling  of  individuals  of  certain  widely  different  races  leads  in  several 
generations  to  sterility.  Examples  of  this  are  the  octoroons,  who  represent  the 
repeated  mingling  in  three  generations  of  whites  and  negroes,  and  the  Lipplapps 
of  Java,  who  represent  in  the  same  way  the  union  of  the  Dutch  and  the  Malays. 
This  is  an  illustration  of  race  degeneration.  It  has  been  supposed  that  octoroons 
are  absolutely  sterile,  but  this  is  not  entirely  true. 

Treatment  of  Sterility. — Acquired  Malposition. — Much  of  the  reconstructive 
surgery  for  sterility  is  directed  to  cases  of  malposition  of  the  uterus. 

It  may  be  said  in  this  connection  that  where  sterilit}^  is  due  to  a  uterine 
displacement  which  is  the  result  of  childbirth  or  miscarriage,  a  correction  of  the 
malposition  may  be  expected  to  cure  the  sterility  with  a  reasonable  amount  of 
certaintj"  if  all  other  causes  can  be  excluded. 

Hypoplastic  Malpositions.- — Operative  treatment  for  hypoplastic  malposi- 
tions is  successful  in  only  a  limited  number  of  cases.  We  have  pointed  out  that 
in  these  cases  there  may  be  numerous  possible  factors  causing  the  sterility,  of 
which  the  misplacement  is  only  one.  Inasmuch  as  the  malposition  of  the  uterus 
is  the  only  tangible  element  in  the  condition  which  we  can  materially  correct, 
operative  treatment  is  usually  indicated,  for  success  follows  sufficiently  often 
to  make  surgical  interference  justifiable,  though  with  our  present  knowledge 
it  must  be  admitted  that  it  is  always  to  a  certain  extent  experimental. 

Surgical  treatment  is  in  most  cases  directed  to  a  correction  of  the  anteflexion 

36 


562  GYNECOLOGY 

and  stenosis  of  the  cervix,  and  ranges  from  simple  dilatation  to  elaborate  ab- 
dominal or  vaginal  operations.  Simple  dilatation  -without  other  surgical  meas- 
ures is  successful  in  a  small  number  of  cases.  It  happens  sufficiently  often, 
however,  to  make  it  advisable  in  any  hj-poplastic  case,  either  as  an  operation 
itself  or  in  connection  T\-ith  some  other  more  elaborate  procedure.  Dilatation, 
however,  has  no  permanent  effect  on  the  position  of  the  womb,  and  the  flexion 
practically  always  reasserts  itself  ahnost  immediately.  The  use  of  a  uterine 
stem-pessary  after  dilatation  according  to  the  method  recommended  by  Daven- 
port many  years  ago  is  not  infrequently  successful  according  to  those  who 
employ  the  method.  It  should  be  remembered,  however,  that  the  placing  of  a 
stem-pessary  in  the  uterus  is  unsurgical  in  principle  and  is  sometimes  followed 
by  infection  of  the  tubes. 

Operations  for  sterility  in  hypoplastic  conditions  of  the  uterus  are  identical 
with  those  for  dj^smenorrhea  (see  page  520). 

After  aU  has  been  said  of  operations  for  sterility  in  hypoplastic  cases,  it 
must  be  admitted  that  only  a  comparatively  smaU  percentage  result  in  suc- 
cess. It  is  a  question,  therefore,  if  such  haphazard  operating  is  justifiable. 
It  may  be  answered  that  in  the  majority  of  these  cases  the  sterility  is  asso- 
ciated with  severe  dj'smenorrhea,  and  that,  in  general,  the  same  operation  is 
indicated  for  both  conditions  and,  therefore,  justifiable  for  the  rehef  of  pain. 
None  of  the  operations  are  dangerous,  and  do  not,  therefore,  entail  an  un- 
justifiable risk,  cA'en  in  the  absence  of  dysmenorrhea. 

Salpingitis. — Although  gonorrheal  salpingitis  is  one  of  the  most  conmion 
causes  of  sterihty,  all  women  who  have  had  salpingitis  are  not  necessarily 
doomed  to  sterihty.  We  have  a  sufficient  number  of  cases  in  our  series  to  show 
conclusively  that  in  some  instances  gonorrhea  of  the  tubes  heals  spontaneously,, 
the  fhial  proof  of  which  is  a  later  normal  pregnancy.  A  case  of  salpingitis  which 
is  afterward  complicated  by  a  tubal  pregnancy  cannot  be  said  to  be  cured,  as 
the  permanent  results  of  the  pathologic  processes  in  the  mucous  membrane  are 
enough  to  interfere  with  the  complete  passage  of  the  ovum.  If,  however,  a 
normal  pregnane}^  takes  place,  we  may  regard  the  tube  as  ha\dng  been  restored 
to  its  normal  functionating  condition. 

It  is  this  possibility  of  restoring  a  woman  to  fertihty  that  forms  the  most 
important  foundation  stone  of  conser^-ative  surgery  in  cases  of  gonorrheal 
salpingitis,  and  is  more  to  be  considered  than  the  matter  of  retaining  functionat- 
ing organs,  because,  as  we  constantly  .see,  the  general  results  as  to  future  general 
health  are  apt  to  be  better  after  hysterectomy  than  after  partial  conservation. 

The  cases  in  which  an  attempt  should  be  made  to  secure  fertihty  are  young 
tmmarried  women,  or  married  women  who  are  particularly  anxious  to  have 
children.  The  subject  should  always  be  considered  before  operating  on  such 
cases,  and  should  be  discussed  with  the  patient  beforehand.  The  possibility  of 
leaA-ing  the  tubes  in  a  condition  where  impregnation  may  later  take  place  cannot 
always  be  foretold,  as  it  is  not  uncommon  to  find  them  much  more  diseased 


SPECIAL   GYNECOLOGIC   DISEASES 


563 


than  was  supposed,  so  that  the  patient  must  be  made  thoroughly  acquahated 
with,  the  chances  in  order  to  avoid  later  disappointment.  On  the  other  hand, 
many  patients  are  overanxious  to  have  all  their  pehdc  organs  removed  after 
the  discomforts  and  suffering  of  pehic  inflammatory  disease,  and  it  is  some- 
times necessar}^  for  the  surgeon  to  urge  such  patients  to  take  the  chances  of  a 
conservative  operation  in  order  to  provide  against  possible  later  domestic 
unhappiness. 

The  various  operations  for  securing  or  preser\"ing  fertility  in  women  suffering 
from  chronic  pelvic  inflammation  are  described  in  Part  III.  It  not  infrequently 
happens  that  although  one  tube  is  obliterated,  adherent,  and  seriously  damaged, 
the  opposite  tube  remains  patent  and  '^ith  few  adhesions.  In  such  a  case  the 
diseased  tube  should  be  completely  exsected  from  the  cornu  of  the  uterus.  The 
removal  or  conservation  of  the  ovary  depends  on  the  amount  of  destruction 
which  it  has  suffered  and  also  on  the  condition  of  the  other  ovarj'.  In  some 
cases  we  have  flushed  out  the  remaining  tube  with  70  per  cent,  alcohol  and 
sterile  water.     "Wliether  this  maneuver  is  of  any  value  is  doubtful. 

In  another  class  of  cases  both  tubes  are  sealed  at  the  fimbriated  end,  yet 
have  escaped  serious  injury  otherwise.  In  such  a  case  it  may  be  possible  to 
preserve  a  portion  of  both  tubes  bj^  resecting  the  outer  third,  or  it  maj^  be  neces- 
sary to  extirpate  one  and  preserve  a  part  of  the  other.  Resection  of  a  portion 
of  a  tube  should  never  be  employed  except  as  a  means  to  preserve  the  pa- 
tient's fertility,  for  there  is  always  the  possibility  of  a  later  acute  infection  of  the 
proximal  stump.  If  the  tube  is  resected  for  the  pm-pose  of  fertihty  it  is  left  as 
long  as  possible,  and  a  plastic  operation  is  performed  on  the  distal  end  of  the 
tube  in  order  to  preserve  an  open  ostium.  The  usual  method  of  performing  a 
so-called  stomatoplastic  operation  on  the  stump  of  the  tube  is  simply  to  ap- 
proximate the  tubal  mucous  membrane  to  the  peritoneal  covering  of  the  tube 
by  means  of  fine  interrupted  catgut  sutures.  A  more  effective  method  is  to  slit 
the  tube  longitudinally  for  ^  to  f  inch  and  to  apply  only  enough  sutures  to 
control  the  bleeding,  as  it  is  thought  that  the  sutures  favor  an  adhesive  closure 
of  the  lumen.  Still  another  method  is  to  engage  the  end  of  the  tubal  stump  in  a 
sHt  in  the  ovary. 

A  third  class  of  cases,  where  fertility  is  desired,  comprises  those  conditions 
where  both  tubes  are  beyond  repair,  but  where  one  or  both  ovaries  are  iti  fairly 
good  condition.  The  only  possibilitj^  in  these  cases  is,  after  extirpating  the  tubes, 
to  implant  a  piece  of  ovary  in  each  cornu  of  the  uterus.  The  chances  of  success 
in  this  operation  are,  of  course,  extremely  small.  Successful  results  by  this 
method  have  been  secured  in  animals,  and  a  few  cases  of  impregnation  have  been 
reported  in  human  beings.     (See  below.) 

In  cases  where  pregnane}^  has  ensued  after  leaving  an  entire  tube  it  maj^  be 
asked  if  the  operation  has  been  instrumental  in  securing  this  result.  We  are 
inclined  to  think  that  it  is,  though  indirectly.  The  removal  of  the  more  activeh' 
diseased  tube  bj-  a  careful  technical  operation,  and  the  usual  suspension  of  the 


564  GYNECOLOGY 

uterus  by  some  appropriate  method,  leave  the  organs  in  a  position  much  more 
favorable  for  impregnation,  and  in  many  cases  prevent  the  further  formation  of 
immobilizing  and  obstructive  adhesions.  The  general  health  of  the  patient  is 
usually  greatly  improved,  while  the  sexual  functions,  which  are  sometimes  dis- 
turbed by  the  chronic  pelvic  disease,  may  be  restored  to  the  normal  condition. 

In  order  to  determine  the  percentage  of  possible  impregnation  after  chronic  pelvic  inflam- 
mation we  wrote  letters  to  many  patients  who  had  had  conservative  operations  for  this  disease, 
and  have  a  series  of  90  cases  of  whom  we  have  exact  data.  All  of  these  90  cases  were  in  the 
child-bearing  period.  All  had  pelvic  inflammatory  disease,  a  very  high  percentage  of  which 
was  doubtless  of  gonorrheal  origin.  Microscopic  examination  of  the  portions  of  the  tubes  or 
ovaries  confirmed  in  every  case  the  diagnosis  of  salpingitis.  In  all  of  the  cases  operations  were 
done  which  would  conceivably  leave  the  patient  fertile,  and  comprised  such  procedures  as 
exsection  of  one  tube,  resection  of  both  tubes,  exsection  of  one  tube  and  resection  of  the  other, 
resection  of  the  tube  and  insertion  of  the  ostium  of  the  tubal  stump  in  the  ovary,  etc.  In  some 
cases  both  tubes  were  exsected  and  ovarian  tissue  implanted  in  the  uterine  cornua.  No  case 
was  included  where  both  tubes  were  exsected  without  implantation. 

Of  the  90  cases,  16,  or  17.7  per  cent.,  conceived  at  varying  times  after  the  operation.  Of 
these  16  conceptions,  11  were  normal  pregnancies,  while  5  ended  in  abortion. 

In  55  cases  an  entire  tube  was  left  in,  and  of  these,  10  conceived,  or  18  per  cent.  In  35 
cases  both  tubes  were  operated  on,  one  or  both  of  them  being  resected,  and  having  a  stomato- 
plastic  done  on  the  ostiimi  of  the  stump  of  at  least  one.  In  other  words,  these  cases  had  only  a 
part  of  one  tube  or  parts  of  both  tubes  left.  One  was  a  case  of  implantation  of  ovaries  in  the 
uterine  cornua.     Of  the  35  cases,  6  conceived,  or  16.8  per  cent. 

In  the  90  cases  no  calculation  was  made  of  the  absence  of  exposure  to  conception  from  non- 
marriage,  divorce,  widowhood,  continence,  use  of  preventives,  etc.,  which  if  such  data  were  in- 
cluded would  reduce  the  total  number  somewhat  and  increase  the  percentage  of  fertihty. 

The  high  percentage  of  abortions  is  noticeable,  and  is  not  easily  explained  except  on  the 
theory  that  some  chronic  change  has  occurred  in  the  endometrium  which  has  left  it  unsuitable 
soil  for  the  nom-ishment  of  the  fetus.  The  condition  commonly  foimd  in  the  endometrium  is  a 
chronic  interstitial  endometritis. 

Endocervicitis. — Some  of  the  most  brilhant  results  in  the  treatment  of 
sterility  are  those  gained  when  the  condition  is  due  to  endocervicitis.  As  we 
have  seen,  conception  may  be  prevented  in  these  cases  by  the  mucous  secretion, 
which  either  blocks  the  passage  of  the  spermatozoon  mechanically  or,  by 
becoming  acid,  destroys  its  vitality.  Success  in  these  cases  depends,  of  course, 
on  the  integrity  of  the  other  pelvic  organs. 

In  mild  cases  of  endocervicitis  a  simple  cureting  and  thorough  removal  of  the 
plug  of  mucus  is  often  followed  by  early  conception.  If  it  is  suspected  that  the 
endocervicitis  is  due  to  gonorrhea,  great  care  should  be  exercised  in  cureting 
the  cervix,  for  it  is  not  difficult  to  extend  the  disease  to  the  tubes.  The  operation 
should,  therefore,  be  kept  below  the  level  of  the  internal  os. 

When  endocervicitis  resists  all  ordinary  treatment  it  is  necessary  to  resort 
to  surgical  measures,  the  best  operation  being  that  of  Schroder,  by  which  the 
most  of  the  mucous  membrane  of  the  cervix  is  exsected.  We  have  performed 
this  operation  several  times  for  sterility,  but,  though  it  has  been  successful- in 
removing  the  discharge,  conception  has  not  taken  place  in  any  of  the  cases. 
This  may  be  due  to  undetected  adnexal  disease.     It  is  possible,  too,  that  the 


SPECIAL   GYNECOLOGIC   DISEASES  565 

removal  of  the  cervical  mucus  is  a  factor  in  the  continued  sterility,  for  it  is 
thought  that  this  mucus  is  of  great  importance  to  the  spermatozoon.  On  the 
other  hand,  we  have  observed  several  cases  of  impregnation  after  high  amputa- 
tion of  the  cervix. 

Mild  Disturbance  of  Endocervix.— The  physician  is  frequently  called  upon 
to  treat  cases  of  sterility  in  which  no  definite  anatomic  or  constitutional  cause 
for  the  condition  either  in  husband  or  wife  can  be  discovered.  It  is  probable 
that  in  a  certain  number  of  these  cases  there  is  some  disturbance  in  the  chemical 
reaction  of  the  cervical  or  vaginal  secretions.  The  alkahnity  of  the  cervical 
secretion  is  absolutely  essential  for  the  passage  of  the  spermatozoon  into  the 
uterine  cavity,  and  it  is  likely  that  mild  catarrhal  conditions  of  the  endocervix 
may  modify  the  secretion  so  that  it  becomes  hostile  to  the  life  of  the  germ-cell. 
It  is  possible,  too,  that  mild  catarrhal  or  other  disturbances  of  the  endocervk 
may  interfere  with  the  proper  functioning  of  the  cervical  glands  during  cohabita- 
tion. It  has  been  shown  that  normally  these  glands  secrete  and  press  out 
during  sexual  excitement  fine  mucous  threads  from  their  ducts.  These  threads 
(so-called  "Kristeller")  are  alkahne  in  reaction,  and  are  the  paths  by  which 
the  spermatozoa  mount  into  the  cer\dcal  canal.  There  is  no  doubt  that  mild 
inflammatory  processes  or  the  retention  of  inspissated  mucus  in  the  cervix  may 
interfere  with  this  important  function. 

Ovarian  Implantation  and  Transpla7itation.— When  one  considers  the  extra- 
ordinary success  that  has  been  attained  in  modern  times  by  the  transplanta- 
tion of  various  organs  of  the  body,  one  cannot  help  feehng  that  this  field  of  sur- 
gery may  in  time  become  of  value  in  the  treatment  and  cure  of  certain  forms  of 
sterility.  Investigators  are  working  continually  in  this  fine,  and  a  certain 
amount  of  success  has  been  attained,  especially  in  animals.  It  is  e\adent  that 
transplanted  ovarian  tissue  is  enabled,  for  a  while  at  least,  to  retain  its  function, 
though  eventual  atrophy  usually  takes  place  in  a  comparatively  short  period  of 
time.  We  are  here  chiefly  interested  in  those  experiments  which  have  resulted 
in  impregnation.  Numerous  instances  have  been  reported  in  animals  where 
successful  pregnancy  has  resulted  both  from  auto-  and  heterotransplantation. 
Among  those  who  first  reported  successful  results  were  Krauer,  Ribbert,  Her- 
litzka,  Grigorieff,  and  Rubinstein.  In  one  case  a  rabbit  became  pregnant  one 
and  one-half  years  after  the  operation.  Grigorieff  saw  4  out  of  12  rabbits  be- 
come pregnant  after  transplantation.  In  more  recent  times  interesting  experi- 
ments have  been  carried  on  to  test  the  influence  of  heredity  in  cases  of  hetero- 
transplantation, by  which  it  is  found  that  the  heritable  qualities  of  the  original 
germ-cells  are  not  changed  by  the  new  host. 

A  few  cases  of  impregnation  following  transplantation  in  human  beings  have  been  re- 
ported.    The  most  famous  one  is  that  of  Morris.     Morris'  case  was  one  of  pelvic  peritomtis 
in  which  both  adnexa  were  removed  and  a  piece  of  ovary  implanted  m  the  end  of  one  tube. 
■  This  patient  aborted  four  months  after  the  operation  and  then  menstruated  for  four  years. 
Frank  in  1898  reported  3  cases  of  autotransplantation  of  the  ovary,  m  one  of  which  preg- 


566  GYNECOLOGY 

nancy  going  to  full  term  took  place.  In  another,  probable  abortion  occurred,  and  in  a  thii-d 
there  was  a  suspected  extra-uterine  pregnancy.  In  1905  Halhday-Crom  reported  the  following 
case:  A  patient  had  amenorrhea  following  a  miscarriage,  with  symptoms  of  change  of  life. 
An  operation  was  performed  and  the  ovaries,  which  showed  small  cystic  degeneration,  were  re- 
moved and  an  ovary  from  another  woman  was  implanted.  Menstruation  appeared  four  months 
later,  and  four  years  after  conception  took  place,  vnth  normal  birth. 

We  have  had  one  case  similar  to  that  reported  by  Morris  in  which  abortion  probably  took 
place  several  months  after  operation.  The  case  was  reported  as  one  of  abortion  by  her  family 
physician,  but  as  the  products  of  conception  were  not  seen  it  cannot  be  regarded  as  absolutely 
proved.     Franklin.  H.  Martin  and  Malcolm  Storer  have  reported  similar  cases. 

The  lack  of  success  that  most  ovarian  transplantations  meet  with  is  undoubt- 
edly due  to  our  lack  of  knowledge  of  a  proper  technic,  and  the  more  or  less 
accidental  successes  which  occasionallj^  take  place  con^dnce  one  that  sooner  or 
later,  as  the  science  of  surgery  advances,  a  means  will  be  found  of  transplanting 
the  ovary  so  as  to  maintain  its  functions  with  constant  result.  If  such  a  result 
can  be  attained,  many  cases  of  sterility  due  to  gonorrheal  or  tubercular  disease 
or  to  ovarian  deficiency  will  be  curable.  In  the  case  of  transplantation  from 
another  woman  the  question  of  who  is  the  mother  would  become  an  important 
one.  According  to  law,  the  woman  who  bears  the  child  would  be  regarded  as  the 
mother,  but  from  a  biologic  standpoint  the  woman  who  original^  produced 
the  germ-cells  of  the  ovary  should  be  considered  the  true  mother,  for  from  her 
the  child  would  derive  its  heritable  characteristics. 

Organotherapy. — For  a  full  discussion  of  this  subject,  see  page  64.  It  may 
be  said  here  that  the  administration  of  ovarian  extracts  has  had  very  little  effect 
in  the  treatment  of  sterility. 

Artificial  Im-pregnation. — At  the  present  day  very  little  is  heard  of  artificial 
impregnation  in  the  human  race,  the  practice  having  fallen  into  a  certain  amount 
of  disrepute  as  a  result  of  rehgious,  social,  and  even  legal  objections.  There  is 
no  doubt,  however,  that  the  great  success  that  has  been  attained  in  recent 
years  in  the  artificial  impregnation  of  domestic  animals  will  lead  eventually  to 
a  more  extended  trial  of  its 'possibilities  in  the  treatment  of  sterihty  in  woman. 
Artificial  fertilization  of  fishes  was  done  successfully  as  early  as  the  j^ear  1700, 
and  has  been  developed  scientifically  since  the  middle  of  the  last  century,  so 
that  at  present  it  is  an  extremety  important  factor  in  the  industry  of  pisciculture. 
In  the  year  1780  Spallanzani  succeeded  in  artificially  fertilizing  a  bitch,  and  was 
the  first  to  impregnate  thus  an  animal  of  the  mammalian  type.  This  experi- 
ment of  Spallanzani  attracted  much  attention  at  the  time,  but  very  little  was 
done  in  animal  fertilization  for  more  than  a  century.  In  recent  times  the  pro- 
cedure has  again  been  taken  up,  and  has  been  put  to  very  practical  use  in  the 
breeding  of  domestic  animals.  Everest  Millais  reported  15  successful  results 
out  of  19  trials  in  fertilizing  bitches,  and  showed  that  these  results  equaled 
those  of  natural  methods.  Elias  Iwanoff,  a  Russian,  worked  on  the  artificial 
breeding  of  horses,  and  in  1907  reported  that  results  were  even  more  successful 
than  by  natural  breeding.     He  succeeded  in  fertifizing  mares  that  had  pre- 


SPECIAL   GYNECOLOGIC    DISEASES  567 

viously  been  sterile.  His  experiments  with  cattle,  sheep,  and  other  domestic 
animals  produced  a  like  result.  Since  then  the  process  has  been  widely  adopted 
by  breeders  of  animals. 

To  Marion  Sims  belongs  the  credit  of  being  the  first  to  fertihze  a  woman 
artificially,  which  he  did  in  1866.  The  operation,  however,  has  been  Httle  prac- 
tised, and  only  a  comparatively  few  cases  have  been  reported.  Rohleder,  in  his 
monograph,  collects  all  the  cases  from  the  literature,  including  his  own,  and, 
making  allowances  for  several  doubtful  instances,  reports  65  cases  with  21  suc- 
cessful results.  Doderlein  has  reported  another  case.  The  subject  has  been 
exhaustively  treated  by  Rohleder  in  an  appendix  to  his  book  entitled  "Die 
Zeugung  beim  Menschen,"  to  which  the  reader  is  referred  for  a  detailed  descrip- 
tion of  the  operation.  The  technic  is  extremely  simple,  and  by  the  method 
suggested  by  Rohleder  there  seems  Httle  danger  of  sepsis  if  proper  precautions 
are  taken.  By  this  method  the  semen  is  injected  into  the  cervical  canal  after 
a  slight  dilatation. 

By  the  technic  used  by  Sims  the  few  drops  necessary  for  injection  were  col- 
lected from  the  posterior  vault  of  the  vagina  post  coitum.  Rohleder  criticizes 
this  method,  because  the  spermatozoa  are  deposited  and  left  for  a  time  in  the 
acid  secretion  of  the  vagina,  which  is  inimical  to  their  life.  He,  therefore,  takes 
the  semen  from  a  condom  and  injects  it  immediately  into  the  cervix.  The 
operation  is  done  during  the  first  few  days  after  menstruation  and  immediately 
post  coitum.  This  last  he  considers  important,  as  at  that  time  the  alkaline 
secretion  of  the  cervix  is  more  profuse,  and  hence  more  favorable  to  the  fife  of 
the  spermatozoon.  It  is  of  very  great  importance  to  exclude  the  possibifity  of 
a  gonococcus  infection  by  a  careful  examination  of  the  genitalia  of  both  husband 
and  wife.     More  than  one  operation  has  resulted  in  gonorrhea. 

It  is  evident  that  artificial  impregnation  is  only  indicated  when  the  genitafia 
of  the  woman  are  practically  normal  except  for  slight  deviations,  such  as  an- 
teflexion of  the  cervix. 


General  symptomatology  m  Gynecology 

In  treating  gynecologic  patients  it  is  of  extreme  importance  to  learn  the 
essential  symptom  for  which  the  patient  seeks  rehef.  The  essential  symptoms 
in  pelvic  disease  are  quite  definite,  easily  classified,  and  are  comparatively 
reliable  guides  to  a  correct  diagnosis.  In  taking  the  clinical  history  of  a  gjoie- 
cologic  case  the  chief  complaint  must  first  be  sought,  and  this  often  requires 
tact  and  intelhgence.  Women  with  pelvic  disease  usually  suffer  from  a  multi- 
tude of  troubles,  each  one  of  which  they  are  hkely  to  enumerate  before  men- 
tioning the  principal  cause  of  their  suffering.  Many  patients,  from  various 
motives,  purposely  conceal  their  real  trouble  in  giving  their  chnical  history, 
leaving  it  for  the  doctor  to  find  it  out  for  himself,  while  others,  in  the  nervous 
excitement  of  a  consultation,  actually  forget  to  mention  the  most  important 
information. 

Most  of  the  essential  symptoms  of  gynecologic  disease  can  be  -divided  into 
three  main  groups:  (1)  Those  due  to  abnormal  secretion;  (2)  those  due  to  ab- 
normalities of  bleeding,  including  irregularities  of  menstruation;  (3)  those  due 
to  pain.  It  is  the  purpose  of  this  section  to  interpret  these  symptoms  in  their 
relation  to  the  various  diseases  which  may  cause  them. 

SYMPTOMS  DUE  TO  ABNORMAL  SECRETIONS 

Abnormal  secretions  from  the  genital  tract  not  containing  blood  are  gener- 
ally spoken  of  as  leukorrheal  discharges.  If  a  patient  complains  of  leukorrhea 
it  is  necessary  to  know  whether  or  not  it  is  constant;  if  not,  at  what  times  it 
occurs,  especially  with  reference  to  the  menstrual  period;  if  constant,  how  pro- 
fuse it  is;  whether  a  napkin  is  necessary,  etc.  The  patient  must  be  further 
questioned  as  to  the  character  of  the  discharge — is  it  thin  and  watery;  is  it  white 
and  milky;  is  it  thick  and  creamy;  is  it  brownish;  is  it  greenish;  does  it  have  a 
foul  odor;  is  it  accompanied  by  pain;  does  it  irritate  the  external  genitals;  is  it 
affected  by  nervous  excitement  or  exhaustion.  It  is  important  also  to  know  the 
duration  of  the  discharge — did  it  come  on  suddenly;  was  it  associated  at  first 
with  pelvic  pain  or  burning  micturition;  did  it  first  come  on  following  child- 
bearing;  was  it  present  before  marriage,  etc.  The  rephes  to  these  questions  give 
a  most  valuable  clue  to  the  diagnosis. 

The  next  step  is  to  determine  the  seat  of  the  abnormal  secretion,  and  this  is 
done  by  inspection  of  the  external  genitals,  by  digital  examination  per  vaginam, 
and  by  inspection  of  the  vagina  and  cervix  through  a  speculum.  Discharges 
from  the  genital  system  above  the  cervix  must  be  diagnosed  by  inference  and 

568 


GENERAL    SYMPTOMATOLOGY    IN    GYNECOLOGY  569 

by  exclusion  of  the  parts  available  for  direct  examination.  There  is,  of  course, 
some  physiologic  secretion  from  everj^  part  of  the  genital  tract,  from  the  end  of 
the  tubes  to  the  vulva,  but  it  is  not  noticeable  to  the  patient  under  normal  con- 
ditions. Abnormal  secretion  of  the  tube  downward  is  extremely  rare  on 
account  of  the  valve-Hke  action  of  the  tubal  isthmus  which  prevents  fluids  pass- 
ing in  the  direction  of  the  uterus.  Under  rare  conchtions,  however,  a  hydro- 
salpinx or  a  pyosalpinx  may  force  open  the  valve  and  discharge  its  contents 
through  the  uterus  and  vagina.  The  first  is  technically  called  "hydrops  tubse 
profluens,"  and  the  second  "pyosalpinx  profluens."  There  is  a  sudden  unex- 
pected flooding  gush  of  water  or  pus,  as  the  case  may  be,  the  amount  of  which  is 
usually  greatly  exaggerated  in  the  mind  of  the  patient.  In  the  case  of  a  pj^osal- 
pinx  profluens  the  discharge  is  usually  followed  by  rehef  of  pain. 

Non-bacterial  hypersecretion  of  the  endometrial  glands  evidently  takes 
place,  but  it  is  very  difficult  to  identify.  Undoubtedly,  conditions  like  mal- 
positions, adherent  pelvic  peritonitis,  etc.,  which  produce  hyperemia  of  the 
uterus  and  thickening  of  the  endometrium,  intensify  the  natural  secretion. 
The  secretion  under  normal  conchtions  is  very  shght,  composed  as  it  is  of  a 
serous,  albuminous  fluid  material  non-mucoid  in  character.  Conditions  of 
hyperemia  stimulate  also  the  more  active  mucous  glands  of  the  cervix,  so  that 
how  much  of  the  leukorrheal  discharge  is  due  to  the  endometrium  cannot  be 
determined.  It  is  probable  that  the  non-bacterial  discharges  from  the  endo- 
metrium are  rarely  of  much  clinical  importance.  The  temporary  mild  leukor- 
rhea  that  follows  the  catamenia  represents  a  hypersecretion  of  the  endometrial 
glands,  but  must  be  regarded  as  physiologic. 

Bacterial  or  infectious  discharges  from  the  uterine  mucosa  are  comparatively 
uncommon.  The  gonococcus  does  not  have  a  predilection  for  the  endometrium 
and  does  not  often  leave  a  permanent  infection.  Acute  gonorrheal  endometritis 
does,  however,  sometimes  occur,  and  produces  a  characteristic  purulent  dis- 
charge, which  is  always  associated  with  an  infection  of  the  endocervix.  Puer- 
peral sepsis  may  also  cause  an  acute  or  subacute  endometritis  from  which  may 
issue  a  purulent  or  seropurulent  discharge.  From  both  gonorrhea  and  puer- 
peral sepsis  there  may  result  a  chronic  interstitial  endometritis  (g.  v.)  which 
may  produce  a  chronic  leukorrhea. 

Tuberculosis  of  the  endometrium,  a  comparatively  rare  disease,  also  causes 
a  chronic  discharge. 

Other  causes  for  leukorrhea  from  the  uterine  canal  are  sloughing  mucous 
or  myomatous  polyps,  submucous  myomas,  and  adenocarcinoma  of  the  endo- 
metrium. The  amount  and  character  of  the  discharge  depends  on  the  amount 
of  sloughing,  and  may  be  very  abundant  and  exceedingly  fetid,  simulating  that 
from  cancer  of  the  cervix. 

Long-retained  products  of  conception,  besides  producing  menorrhagia  and 
metrorrhagia,  cause  a  uterine  discharge  which,  if  sepsis  is  present,  is  foul  and 
profuse. 


570 


GYNECOLOGY 


Partial  gynatresia,  especially  that  resulting  from  senile  atrophy,  results 
in  retention  of  the  uterine  secretions,  producing  hydrometra  or  pyometra,  which 
may  more  or  less  periodically  discharge  its  contents. 

Most  leukorrhea  comes  from  the  endocervix.  The  glands  of  the  endo- 
cervix  secrete  a  clear  mucus  which  normally  is  hardly  appreciable.  Under 
conditions  of  irritation  or  infection  they  become  very  active  and  pour  forth 
large  amounts  of  mucus,  which  after  reaching  the  vagina  becomes  coagulated 
and  opaque,  so  that  on  issuing  from  the  vagina  it  has  the  characteristic  white 
appearance-  from  which'  the  term  "leukorrhea"  is  taken. 

Non-bacterial  hypersecretion  of  the  endocervical  glands  may  occur  in 
Adrgins,  and  is  sometimes  difficult  to  account  for.  There  often  seems  to  be  an 
associated  nervous  element,  many  of  the  patients  being  of  neurotic  or  excitable 
temperament.  Nervous  excitement  and  fatigue  seem  to  stimulate  the  dis- 
charge. This  can  only  be  accounted  for  on  the  theory  of  a  local  hyperemia  of 
the  genital  organs.  In  many  of  the  cases  of  leukorrhea  in  virgins,  however, 
there  can  be  found  a  true  erosion  of  the  cervix  near  the  external  os,  the  repair 
of  which  will  cause  the  leukorrhea  to  cease.  (The  cause  of  this  so-called  erosio 
virginis  has  been  a  matter  of  doubt,  but  it  may  be  observed  that  in  most  of  the 
cases  there  is  a  malposition  of  the  cervix  resulting  from  a  retroversion  or  ante- 
flexion of  the  body,  so  that  the  cervix  comes  in  contact  with  the  anterior  vaginal 
wall.     The  erosion  may,  therefore,  be  due  to  friction.) 

Lacerations  of  the  cervix  with  ectropion  and  eversion  result  in  a  chronic 
inflammation  and  irritation  of  the  cervical  mucosa,  resulting  in  hypersecretion 
of  the  glands.  There  is  usually  an  associated  mixed  infection  of  various  organ- 
isms. Of  the  bacterial  infections  of  the  cervix,  gonorrhea  is  the  most  common, 
affecting  as  it  does  the  surface  epithelium,  and  producing  later  mixed  infection 
of  the  deep-lying  glands.  The  chronic  endocervicitis  from  chronic  gonorrhea 
(g.  V.)  is  most  persistent  and  difficult  to  treat. 

In  cancer  of  the  cervix,  leukorrhea  is  the  earliest  symptom,  and  is  of  clinical 
importance  on  account  of  its  peculiar  character.  The  discharge  is  thin  and 
watery  as  a  result  of  the  serous  transudation  from  newly  made  capillaries  of  the 
growing  tumor.  Infection  and  sloughing  of  the  cancerous  mass  imbues  the 
discharge  with  a  characteristic  foul,  almost  intolerable  odor. 

A  similar  discharge  may  sometimes  come  from  a  sloughing  myomatous 
polyp  presenting  at  the  cervix. 

Secretion  from  the  vagina  is  normally  very  slight,  and  the  vagina  of  the 
adult  is  also  comparatively  resistant  to  infection.  In  childhood  it  is  very  sus- 
ceptible to  gonorrhea,  and  the  discharge  therefrom  is  exceedingly  purulent, 
abundant,  and  persistent.  Vaginal  discharges  in  mature  women  result  from 
saprophytic  and  fungus  infections  in  the  unclean,  and  from  secondary  infec- 
tions from  neglected  gonorrhea. 

Foul  vaginal  discharges  result  from  long-contained  foreign  bodies.  Of  these, 
the  worst  offender  is  the  vaginal  pessary,  especially  those  of  the  soft-rubber 


GENERAL  SYMPTO:\LlTOLOGY  IX  GYNECOLOGY  571 

variety.  Tampons  are  frequenth'  left  in  from  the  carelessness  of  the  patient 
or  her  physician  and  result  in  a  most  offensive  discharge. 

A  very  unportant  and  too  little  recognized  cause  of  vaginal  leukorrhea  is 
that  which  results  from  senile  atrophy.  The  color  of  the  discharge,  usually 
ver}'  white,  is  due  to  its  containing  a  great  amount  of  desquamated  vaginal 
epithelium.     It  may  be  tinged  \\dth  blood. 

Discharges  from  the  external  genitals  are  usualh'  C[uite  obvious  in  their  origin. 
Chronic  inflammation  of  Bartholin's  glands,  especially  if  an  abscess  has  been 
lanced,  often  results  in  a  discharging  sinus,  from  which  issues  an  irritating  sero- 
purulent  discharge.  Chronic  inflammation  of  Skene's  glands,  vnth.  a  mixed 
infection,  produces  a  like  result,  as  does  also  a  chronic  gonorrheal  urethritis. 

ABNORMALITIES  OF  MENSTRUATION 

Under  menstrual  disorders  are  included  amenorrhea,  menorrhagia  and 
metrorrhagia,  dysmenorrhea,  and  vicarious  menstruation. 

Amenorrhea  is  physiologic  before  puberty,  during  the  months  of  pregnancy, 
and  after  the  menopause.  There  is  some  debate  as  to  whether  the  amenorrhea 
that  accompanies  the  first  months  of  lactation  is  phj^siologic  or  pathologic. 
Normal  lactating  women  menstruate  from  six  weeks  to  four  months  after  labor. 
If  the  amenorrhea  lasts  longer  than  this  it  probably  signifies  a  too  great  atrophy 
of  the  uterus.  In  women  who  nurse  their  children  too  long,  or  who  have  too 
frequently  repeated  labors,  there  is  sometunes  a  long-continued  or  even  per- 
manent amenorrhea  due  to  excessive  genital  atrophy.  Lactating  women 
during  the  amenorrheic  period  do  not  often  conceive. 

Amenorrhea  may  be  the  result  of  genital  aplasia  or  marked  hypoplasia. 
Imperfect  development  of  the  uterus  and  vagina  may  be  associated  with  func- 
tionating ovaries  with  no  appearance  of  blood,  but  with  periodic  monthly  general 
symptoms  of  congestion,  the  so-called  molimina  of  menstruation.  Delayed 
puberty  is  often  evidence  of  some  degree  of  hj^poplasia  or  infantilism,  and  if  the 
defective  development  is  marked,  it  may  be  followed  by  a  premature  climacteric. 

The  absence  of  blood  that  results  from  atresia  of  the  vagina  with  fu\ly 
developed  uterus  and  ovaries  is  not  a  true  amenorrhea,  for  here  the  uterus  actu- 
alty  menstruates,  the  blood  being  dammed  back  in  the  vagina,  uterus,  and 
tubes  (hematocolpos,  hematometra,  and  hematosalpinx). 

Castration  produces  amenorrhea.  The  reported  instances  of  menstruation 
following  castration  are,  many  of  them,  the  result  of  leaving  in  a  small  amount 
of  ovarian  tissue  or  the  possible  presence  of  an  accessor}^  ovary.  Some  of  the 
cases  of  this  kind  are  difficult  to  explain.  Hysterectomy  \\^thout  the  removal 
of  the  ovaries  is  followed  by  cessation  of  the  menses,  though  sometimes  the 
molimina  of  menstruation  may  persist. 

For  the  maintenance  of  the  menstrual  function  onl}^  a  very  small  amount 
of  ovarian  tissue  is  requisite.  This  is  observed  in  bilateral  ovarian  tumors 
even  of  enormous  size,  where,  as  a  rule,  there  is  no  disturbance  of  the  monthlj^ 


572  GYNECOLOGY 

periods.  It  is  stated  (Zacharias)  that  even  though  the  parenchyma  of  the 
ovary  is  destroyed,  the  hilus  of  the  ovary  is  sufficient  to  preserve  menstruation. 
On  the  other  hand,  when  most  of  the  ovarian  tissue  is  destroyed  by  disease  or 
removed  by  operation,  the  menopause  is  usually  premature. 

Amenorrhea  may  be  caused  by  destruction  of  the  uterine  mucosa.  Examples 
of  this  have  been  seen  after  a  too  vigorous  curetment  or  cauterization,  or  chemical 
treatment  of  the  endometrium. 

There  are  certain  general  constitutional  disturbances  which  may  produce 
amenorrhea.  Of  these,  one  of  the  most  important  in  the  young  is  chlorosis, 
though  it  may  also  cause  severe  menorrhagia.  The  same  is  true  of  simple 
anemia.  Why  deficient  blood  suppresses  menstruation  in  one  and  stimulates 
it  in  another  is  an  unsolved  problem. 

Of  very  great  importance  is  the  amenorrhea  which  results  from  disturbances 
of  the  various  glands  of  internal  secretion,  such,  for  example,  as  Basedow's 
disease,  Addison's  disease,  myxedema,  and  the  various  diseases  that  result  from 
disturbances  of  the  pituitary  body.  In  these  conditions  the  amenorrhea  is 
associated  with  an  atrophy  or  defective  development  of  the  internal  and  external 
genitals. 

Defective  ovarian  function,  signified  by  scanty  menstruation,  delayed 
puberty,  or  permanent  amenorrhea,  often  accompanies  abnormal  adiposity  of 
youth  (Fettkinder)  or  the  sudden  rapid  accession  of  fat  in  the  mature,  in  both 
of  which  cases  there  is  usually  some  pathologic  condition  of  one  of  the  internal 
secretory  organs. 

The  relationship  of  tuberculosis  to  amenorrhea  is  of  very  important  chnical 
significance.  All  forms  of  tuberculosis  may  be  associated  with  scanty  or  sup- 
pressed menses,  more  especially  the  genital  and  peritoneal,  and  less  frequently 
the  pulmonary  types. 

Certain  chronic  constitutional  diseases  are  apt  to  be  accompanied  by  amenor- 
rhea. Among  these,  the  most  important  are  diabetes  melhtus  and  insipidus, 
chronic  nephritis,  leukemia,  syphihs,  cancer  cachexia,  morphinism,  and  alco- 
holism. 

Amenorrhea  is  also  common  in  the  various  forms  of  functional  and  chronic 
psychoses,  in  epilepsy,  and  progressive  paralysis. 

Under  the  term  "functional  amenorrhea"  are  classed  such  cases  of  tem- 
porary cessation  of  the  menses  or  delayed  menarche  as  are  not  related  to  any 
definite  pathologic  condition.  One  of  the  commonest  causes  of  functional 
amenorrhea  is  some  sudden  psychic  emotion,  especially  that  of  fear  or  anger. 

The  menses  are  often  suppressed  in  their  course  by  chilling  of  the  body 
from  cold  baths,  exposure  to  the  weather,  wet  feet,  etc. 

Anxiety  from  fear  of  pregnancy  or  from  great  desire  to  have  children  may 
delay  the  period  for  days  or  even  months.  In  the  latter  case,  motions  of  a  child 
may  be  imagined  and  there  may  be  apparent  enlargement  of  the  abdomen. 
These  are  the  so-called  "phantom  pregnancies." 


GENERAL   SYMPTOMATOLOGY   IN    GYNECOLOGY  573 

A  common  cause  of  functional  amenorrhea  is  a  change  of  chmate  or  occu- 
pation, as  seen  commonly  among  domestics. 

Vesicovaginal  fistulas  are  not  uncommonly  associated  with  amenorrhea. 

Menorrhagia. — B}^  this  term  is  meant  excessive  menstruation.  This  may 
consist  of  an  increased  amount  of  blood  at  the  usual  menstrual  period,  or  a 
prolongation  of  the  period,  or  a  too  frequent  recurrence  of  the  menses.  It 
implies  that  during  the  interval  between  the  periods  there  is  no  appearance  of 
blood. 

The  word  "menorrhagia"  must,  to  a  certain  extent,  be  used  relatively.  The 
amount  of  blood  lost  at  each  menstrual  period  varies  considerably  in  different 
individuals,  as  has  been  seen.  What  might  be  a  normal  flow  for  a  robust,  full- 
blooded  matron  might  constitute  a  depleting  hemorrhage  for  a  delicate,  poorly 
nourished  unmarried  woman.  Some  women  have  a  physiologic  interval  of 
twenty-three  days,  but  in  a  woman  whose  normal  interval  is  twenty-eight  days 
the  early  recurrence  of  the  menses  may  be  an  indication  of  serious  disease. 

The  coagulability  of  the  menstrual  blood  is  of  importance,  for  clots  signify 
some  abnormality.  If  the  clotting  is  considerable  the  case  is  usually  to  be 
regarded  as  one  of  menorrhagia. 

It  is  not  always  easy  to  determine  the  existence  or  the  extent  of  the  menor- 
rhagia, as  one  is  obliged  to  rely  chiefly  on  the  patient's  history.  This  includes 
the  routine  questions  as  to  the  time  of  puberty,  length  of  each  menstrual  period, 
regularity  and  duration  of  the  interval,  amount  of  blood  lost,  presence  or  ab- 
sence of  pain,  and  the  date  of  the  last  menstrual  period.  From  these  questions 
fairly  accurate  data  are  gained  as  to  whether  the  patient's  periods  last  over  too 
many  days  or  whether  they  are  too  frequent.  The  amount  of  blood  lost  is  more 
difficult  to  ascertain  unless  the  amount  is  so  great  as  to  cause  flooding,  hemor- 
rhages, fainting  spells,  and  obvious  anemia.  In  the  more  moderate  cases  one 
must  judge  from  inference,  and  this  can  best  be  done  by  inquiry  as  to  the  average 
number  of  napkins  or  pads  used  during  the  period.  Patients  differ  in  this 
respect  according  to  their  social  station  and  personal  cleanliness,  but  if  the  men- 
struation is  sufficient  to  soak  the  pads  a  change  is  imperative,  so  that  in  impor- 
tant cases  the  error  is  not  great.  The  average  normal  woman  of  cleanly  habits 
uses  three  or  four  napkins  a  day,  the  total  number  for  the  period  averaging 
twelve  to  sixteen.  If  more  than  this  are  used,  menorrhagia  is  suspected,  and  if 
the  number  reaches  eight  to  twelve  a  day  the  diagnosis  is  established. 

If  it  appears  evident  from  the  patient's  history  that  she  is  menstruating  too 
much  or  too  often,  the  duration  of  the  condition  must  be  determined.  Has 
menstruation  always  been  profuse  since  it  began;  was  it  increased  by  marriage 
or  childbirth;  does  it  date  from  a  miscarriage;  has  there  ever  been  an  attack  of 
"inflammation  of  the  bowels"  (pelvic  inflammation);  has  the  increase  of  flow 
been  gradual  or  sudden;  has  there  been  enlargement  of  the  abdomen  or  a  lump 
to  be  felt  in  the  abdomen,  are  questions  the  answers  to  which  are  important 
before  making  a  physical  examination. 


574  GYNECOLOGY 

Causes  of  Menorrhagia. — We  have  seen  that  a  menstrual  flow  in  the  newborn 
is  a  physiologic  result  of  the  influence  of  the  placental  tissue  on  the  genital 
organs,  and  that  precocious  menstruation  is  due  to  disturbances  of  the  thymus 
and  pineal  glands. 

Menorrhagia  during  the  first  decade  following  puberty  is  not  uncommon 
and  may  be  very  severe  and  intractable.  Some  of  these  young  patients  are 
chlorotic  and  anemic.  In  others  the  cause  of  the  bleeding  is  obscure.  It  -may 
be,  and  doubtless  often  is,  due  to  some  disturbance  in  the  internal  secretion  of 
the  ovaries  or  of  other  internal  secretory  glands,  or  it  may  be  the  result  of 
defective  musculature  of  the  uterus  or  anomahes  of  the  circulatory  apparatus. 
These  are  only  theories,  and  have  not  yet  been  scientifically  estabhshed.  Un- 
doubtedly, some  cases  of  youthful  menorrhagia  are  the  result  of  masturbation. 

Menorrhagia  may  be  the  result  of  passive  congestion  of  the  uterus,  and  is- 
not  infrequently  seen  with  retroflexion  and  prolapse  of  the  uterus.  It  is  prob- 
ably due  to  a  congestion  of  the  uterine  musculature  which  diminishes  its  power 
of  contraction.  In  cases  of  this  kind  there  is  usually  an  associated  varicose 
condition  of  the  veins  contained  in  the  broad  hgaments. 

Excessive  or  abnormal  coitus  is  said  to  be  a  cause  of  menorrhagia.  Acute' 
infectious  diseases,  especially  influenza,  are  an  occasional  cause. 

Pelvic  conditions  which  tend  to  abnormal  fixation  of  the  uterus,  such  as  the 
adhesions  of  chronic  pelvic  inflammatory  disease,  conduce  to  menorrhagia. 
It  is  difficult  to  say  whether  this  is  due  to  an  interference  with  the  normal 
muscular  contractions  of  the  uterus,  or  whether  it  is  the  result  of  a  chronic 
interstitial  endometritis. 

True  chronic  inflammation  of  the  endometrium,  we  have  seen,  is  not  par- 
ticularly common.  When  it  does  occur,  it  is  usually  the  end-result  of  an  acute 
gonorrhea  or  puerperal  sepsis.  Chronic  endometritis  (q.  v.)  is  apt  to  cause 
menorrhagia.  This  is  especially  true  after  incomplete  abortions,  where  small 
portions  of  fetal  tissue  or  of  blood-clots  become  semi-organized  and  attached 
to  the  uterine  wall  and  serve  as  a  continual  source  of  irritation  to  the  mucosa. 

Hypertrophy  and  hyperplasia  of  the  endometrium  were  formerly  thought 
to  be  the  chief  primary  cause  of  menorrhagia.  Most  of  the  famiUar  conditions 
associated  with  excessive  menstruation,  like  pelvic  inflammations,  fibroids, 
malpositions,  etc.,  were  supposed  to  create  in  some  way  a  thickening  or  inflam- 
mation of  the  endometrium  with  consequent  bleeding.  It  is  true  that  hyper- 
trophied  mucosa  can  usually  be  found  in  such  conditions,  but  it  is  now  known 
that  in  most  cases  the  supposedly  diseased  endometrium  is  no  more  nor  less  than 
a  phase  of  the  physiologic  monthly  cycle  of  congestion. 

Hypertrophy  of  the  endometrium  is  not  found  to  be  a  very  common  cause 
of  menorrhagia,  but  occasionally  the  process  passes  beyond  the  physiologic 
limits  and  becomes  permanent.  The  thickened  endometrium  is  thrown "  up 
into  irregular  folds,  which  may  be  so  pronounced  as  to  assume  a  polypoid  ap- 
pearance.     This  condition,  technically  called  ''polypoid  gland  hypertrophy,'^ 


GENERAL   SYMPTOMATOLOGY   IN    GYNECOLOGY  575 

may  cause  persistent  and  intractable  menorrhagia.  The  etiology  is  obscure. 
An  advanced  form  of  this  disease  is  the  non-malignant  adenoma  of  the  uterus, 
which  causes  excessive  flowing  and  is  not  curable  by  cureting.  It  lacks  the 
microscopic  appearance  and  clinical  course  of  an  adenocarcinoma. 

Tumors  of  the  ovaries  and  operations  on  the  ovaries  have  some  influence 
on  menstruation.  The  non-malignant  tumors,  as  a  rule,  affect  menstruation 
very  Uttle,  but  if  torsion  takes  place,  menorrhagia  is  apt  to  follow.  Malignant 
tmnors  of  the  ovaries  are  very  frequently  accompanied  by  increased  menstrual 
bleeding.  Operations  on  the  ovaries,  especially  resections,  are  often  followed  by 
a  premature  or  profuse  menstrual  period. 

Menorrhagia  in  its  most  characteristic  and  constant  form  occurs  in  connec- 
tion with  uterine  myomas.  The  most  severe  forms  of  menorrhagia  result  from 
submucous  fibroids,  but  all  myomas  of  whatever  kind  have  a  tendency  to  pro- 
duce an  increase  of  the  menstrual  flow.  The  excessive  bleeding  in  the  case  of  a 
submucous  myoma  does  not  come  from  the  mucous  membrane  covering  the 
myoma,  but  from  the  freer  portions,  and  is  always  venous  in  character  (Sampson) . 

Myomatous  polyps  often  cause  menstrual  bleeding  of  extreme  severity,  as 
do  mucous  polyps  of  the  cervix  and  endometrium. 

Menorrhagia  during  the  preclimacteric  and  climacteric  periods  is  very 
common.  This  is  frequently  due  to  the  presence  of  fibroids  of  the  uterus,  and 
occasionally  the  result  of  chronic  hypertrophy  of  the  endometrium,  but  in  a 
great  many  instances  no  anatomic  cause  can  be  found.  There  is  no  doubt  that 
a  loss  of  tone  in  the  musculature  of  the  uterus,  with  consequent  insufficiency 
of  uterine  contraction,  plays  an  important  role  in  these  cases. 

It  is  not  at  all  unlikely  that  the  menstrual  disorders  of  the  climacteric,  as 
well  as  those  of  the  menarche,  are  the  result  of  irregularities  in  the  hormones  of 
the  ovaries.  It  is  thought  by  some  that  practically  all  menorrhagias  are  caused 
ultimately  by  a  disturbance  of  the  internal  secretion  of  the  ovaries,  and  there 
is  much  evidence  that  this  is  true. 

Metrorrhagia. — Uterine  bleeding  that  occurs  independently  of  menstrua- 
tion and  ovulation  is  called  metrorrhagia.  All  metrorrhagia  is  pathologic,  and 
must  always  be  regarded  in  a  serious  light.  Uterine  bleeding  during  preg- 
nancy is  included  as  a  metrorrhagia,  and  usually  signifies  some  disturbance  of 
the  placenta,  though  there  are  cases  where  it  is  evident  that  the  bleeding  comes 
only  from  the  decidua.  This  may  occur  periodically  at  the  usual  time  of  the 
menstrual  wave.  It  cannot  be  regarded  as  a  true  menstruation,  as  it  is  not 
accompanied  by  ovulation.  The  bleeding  that  results  from  separation  of  the 
placenta  and  abortion,  from  placenta  prsevia,  and  hydatidiform  mole  is  metror- 
rhagia, and  is  of  serious  import,  as  is  also  the  continuous  or  interrupted  post- 
partum bleeding  resulting  from  retained  products  of  conception,  placental  polyps, 
and  attached  organized  blood-clots  (sanguineous  mole).  Persistent  bleeding 
after  one  or  more  curetments  for  retained  products  or  hydatidiform  mole  may 
be  indicative  of  chorio-epithelioma. 


576  GYNECOLOGY 

Bleeding  from  the  decidua  of  extra-uterine  pregnancy  is  also  an  important 
form  of  metrorrhagia.  This  may  or  may  not  be  preceded  by  a  period  of  amenor- 
rhea, for  a  tubal  abortion  not  infrequently  occurs  within  the  first  month  of 
pregnancy.  The  bleeding  of  the  decidua  may,  therefore,  occur  at  the  time  of  or 
previous  to  the  regular  menstrual  period.  Abortion  within  the  first  month  is 
rare  in  uterine  pregnancy,  but  in  tubal  pregnancy  it  is  said  that  it  takes  place 
in  one-fourth  of  the  cases  (Baisch). 

Outside  of  the  various  conditions  referable  to  pregnancy,  metrorrhagia  is 
usually  due  to  malignant  tumors  or  necrotic  polyps.  In  these  cases  the  bleeding 
is  the  result  of  the  breaking  off  of  bits  of  tissue  from  the  growth  or  from  the 
erosion  of  blood-vessels.  The  bleeding  may  be  constant,  or  it  may  result  from 
energetic  movements  of  the  patient,  from  coitus,  or  from  digital  examinations. 

Of  this  class  of  cases  the  most  common  and  most  important  are  those  of 
cancer  of  the  cervix.  The  bleeding  may  be  very  profuse,  but  is  always  venous 
in  character  and  is  rarely  fatal.  Bleeding  from  cancer  of  the  body  is  similar 
to  that  from  cervical  cancer,  but,  as  a  rule,  is  less  severe.  Bleeding  from 
necrotic  polyps  varies  from  a  slight  tinge  of  blood  to  very  serious  hemorrhages. 

After  the  menopause  all  bleeding  is  "metrorrhagic"  and  should  cause  grave 
concern,  with  immediate  and  thorough  investigation.  Besides  cancer  of  the 
cervix  and  body  and  necrotic  polyps,  hemorrhages  at  this  period  often  indicate 
the  degeneration  of  uterine  fibroids.  It  should  be  borne  in  mind,  however,  that 
mild  bleeding  after  the  menopause  is  very  frequently  due  to  senile  atrophy  and 
vaginitis,  which,  together  with  the  leukorrheal  discharge  that  is  usually  present, 
may  closely  simulate  the  hemorrhage  of  cancer. 

Various  ulcerations  of  the  vagina  and  cervix,  such  as  result  from  foreign 
bodies  like  ill-fitting  pessaries,  may  cause  metrorrhagia. 

Severe  lacerations  of  the  cervix,  with  ectropion  and  erosion,  sometimes  cause 
bleeding,  especially  after  coitus.  In  cases  of  this  kind  a  specimen  should 
always  be  removed  and  examined  microscopically. 

PAIN 

Pain  plays  a  somewhat  illusory  part  in  pelvic  symptomatology,  for  many 
of  the  most  serious  conditions  often  exist  without  giving  the  patient  discomfort. 
This  is  due  to  the  fact  that  the  pelvic  organs,  though  well  supplied  with  nerves 
from  the  sympathetic  system,  are  rather  scantily  endowed  with  sensory  fibers. 
Thus,  the  cervix  uteri  is  surprisingly  anesthetic  as  far  as  the  internal  os,  where, 
however,  an  extremely  sensitive  area  is  encountered.  The  uterus  and  ovaries, 
too,  are  quite  insensitive  to  pain,  popular  belief  to  the  contrary.  The  pelvic 
peritoneum,  on  the  other  hand,  is  very  sensitive  and  is  an  important  factor  in 
the  symptomatology. 

Although  the  relationship  of  pain  to  pelvic  disease  is,  in  a  certain  sense, 
secondary  to  the  objective  symptoms  of  abnormal  secretion  and  menstruation, 


GENERAL   SYMPTOMATOLOGY   IN    GYNECOLOGY  577 

nevertheless  a  proper  interpretation  of  it  is  very  necessary.  It  has  been  a 
general  belief  that  many  of  the  pelvic  pains  of  which  women  complain  are  from 
a  neurotic  or  hysteric  source.  This  idea  has  been  greatly  exaggerated  and  has 
led  to  much  improper  treatment,  and  it  is  the  purpose  of  the  writer  to  attempt 
to  show,  both  in  this  section  and  in  that  on  Nervous  Diseases,  that  practically 
all  pelvic  pain  has  a  definite  anatomic  and  pathologic  basis. 

Affections  of  the  cervix,  on  account  of  its  insensibility,  cause  no  local  pain. 
Even  the  most  extensive  cancer  causes  no  sensation  in  the  cervix  itself,  pain 
in  this  disease  not  appearing  until  there  has  been  extension  into  the  parametrium 
or  metastasis  into  the  regional  lymph-glancls.  Lacerations,  erosions,  and 
ulcerations  of  the  cervix  cause  no  direct  subjective  symptoms,  nor  does  acute 
infection  such  as  results  from  gonorrhea.  The  region  of  the  internal  os  is  ex- 
tremely sensitive,  as  is  readily  observed  in  passing  a  sound  into  the  uterine  canal. 
^  This  sensitiveness  is  apparent  in  the  pains  of  essential  dysmenorrhea,  in  the 
agonies  of  childbirth,  and  in  the  painful  expulsion  of  clots  in  menorrhagia. 
It  is  quite  possible  that  the  backache  of  retroflexion  is  a  referred  pain,  actually 
localized  at  the  junction  of  the  body  and  neck  of  the  uterus. 

The  canal  of  the  uterine  body  is,  to  a  certain  degree,  sensitive.  This  is 
shown  by  pain  and  tenderness  of  the  uterus  in  acute  infections  of  the  endo- 
metrium and  occasionally  in  permanent  gland  hypertrophy.  The  pain  of  so- 
called  uterine  colic,  such  as  results  from  contractions  of  the  uterus  on  a  gauze 
packing,  is  probably  referable  to  the  region  of  the  internal  os. 

Much  of  the  pain  from  infections  of  the  pelvis  has  its  seat  in  the  peritoneum. 
Acute  salpingitis  is  extremely  painful,  but  this  is  due  chiefly  to  peritonitis. 
Distention  of  the  tube  seems  to  cause  Uttle  discomfort,  for  non-adherent  hydro- 
salpinx is  insensitive,  while  the  distention  of  the  tube  by  ectopic  pregnancy 
usually  gives  no  pain  before  rupture. 

The  rupture  of  a  tubal  pregnancy  produces  the  most  severe  lancinating  pain, 
which  is  probably  the  result  of  the  sudden  gush  of  blood  into  the  peritoneal 
cavity  (Baisch).  Subsequent  gushes  of  blood  over  the  peritoneal  surface  are 
accompanied  by  lancinating  pains. 

The  subject  of  ovarian  pain  is  one  about  which  there  is  much  misappre- 
hension. All  pains  in  the  sides  of  the  pelvis  are  commonly  referred  to,  both  by 
patients  and  their  physicians,  as  pains  in  the  ovaries,  whereas,  as  a  matter  of 
fact,  the  ovaries  are  comparatively  insensitive  organs.  It  is  well  known  that 
even  the  largest  ovarian  tumors  are  painless  so  far  as  the  ovarian  tissue  is  con- 
cerned. If,  however,  torsion  occurs  there  is  intense  pain,  due  to  peritonitic 
irritation  (Baisch).  It  is  a  mistake  to  suppose  that  small  cystic  degeneration 
of  the  ovaries  causes  pain.  This  process  has  been  shown  to  be  physiologic  up 
to  a  certain  extent,  but  even  if  it  becomes  pathologic  and  reaches  the  stage  of 
retention  cysts,  there  is  no  pain  unless  the  cyst  becomes  twisted  or  involved  in 
peritoneal  adhesions. 

Chronic  oophoritis  resulting  from  a  true  inflammation  and  infiltration  of 

37 


578  GYNECOLOGY 

the  ovarian  stroma  doubtless  causes  pain,  but  it  is  difficult  to  differentiate  the 
pain  that  comes  from  the  ovaries  and  that  which  is  produced  by  the  surrounding 
peritonitic  inflammation  which  usually  accompanies  the  oophoritis. 

Ovarian  neuralgia  is  a  term  often  applied  to  severe  pains  felt  in  the  pelvis, 
especially  by  neurotic  patients  in  whom  no  definite  anatomic  abnormality  can 
be  made  out  by  digital  examination.  It  is  very  doubtful  if  there  is  a  true 
ovarian  neuralgia,  and  it  is  probable  that  cases  of  this  kind  are  imperfectly 
diagnosed  as  to  their  pelvic  condition. 

The  most  common  source  of  pelvic  pain  is  that  which  comes  from  inflamma- 
tion or  irritation  of  the  peritoneum.  In  the  acute  infections  this  is  entirely 
obvious.  When  pelvic  tumors  like  uterine  fibroids  and  ovarian  cysts  become 
painful  and  tender  it  is  almost  certain  that  they  have  become  complicated  by 
adhesive  peritoneal  irritation  or  inflammation.  Chronic  adhesive  peritonitis 
of  the  pelvis  is  far  more  common  than  is  ordinarily  realized,  and  even  a  mild 
grade,  with  few  adhesions  of  the  adnexa,  may  cause  very  discomforting  pain. 
It  is  possible  that  pelvic  adhesions  may  exist  to  a  very  considerable  extent  and 
yet  remain  undetected  by  the  most  expert  examination.  It  is  easy  to  see  how 
such  a  condition  might  be  regarded  as  an  example  of  "ovarian  neuralgia." 

When  the  pelvic  adhesions  involve  the  neighboring  organs  the  pain  may  be 
referred  to  these  organs,  namely,  the  bladder,  the  rectum,  the  appendix,  and 
the  colon.     The  source  of  the  pain  is,  however,  peritoneal  in  each  case. 

An  extremely  important  type  of  pelvic  pain  is  that  which  is  represented  by 
pelvic  pressure.  This  may  be  exerted  in  three  ways:  (1)  By  the  direct  pressure 
force  of  a  growing  incarcerated  tumor;  (2)  by  the  force  of  gravity  resulting  from 
abnormally  heavy  organs,  and  (3)  by  a  loss  of  integrity  of  the  supporting  struc- 
tures, so  that  the  pelvic  diaphragm  no  longer  properly  counteracts  the  normal 
abdominal  pressure. 

Examples  of  tumors  that  may  become  incarcerated  are  the  retroflexed 
pregnant  uterus,  large  myomata  growing  from  the  posterior  wall  of  the  uterus, 
usually  pedunculated,  ovarian  cysts,  especially  those  that  are  adherent  or 
growing  between  the  leaves  of  the  broad  ligament,  and  th.e4arge,  rapidly  growing 
postperitoneal  tumors.  The  pressure  pain  in  these  cases  is  general  and  becomes 
more  severe  as  the  tumor  increases.  Pressure  on  the  ischiadic  nerves  causes 
pain  radiating  into  the  legs.  In  advanced  cases  symptoms  from  obstruction 
of  the  rectum  and  bladder  ensue. 

Downward  pressure  from  gravity  is  most  often  caused  by  uterine  myomas, 
when  the  tumors  grow  in  such  a  way  as  to  push  the  uterus  downward  in  the 
direction  which  it  takes  in  prolapse.  Most  fibroids  of  any  significant  size  and 
weight  cause  pressure  symptoms,  but  some  do  not,  and  others  grow  in  such 
a  way  as  actually  to  lift  the  uterus  into  a  higher  plane  in  the  pelvis.  For  this 
reason  myomatous  tumors  sometimes  grow  to  a  large  size  without  giving  the 
patient  any  discomfort.  Gravity  pressure  also  results  from  large  congested, 
heavy  uteri,  even  if  not  retro  verted  or  prolapsed.     This  is  not  infrequently  seen 


GENERAL   SYMPTOMATOLOGY   IN    GYNECOLOGY  579 

after  repair  of  pelvic  relaxation  and  suspension  of  the  uterus,  especially  if  it  be 
attached  to  a  deficient  abdominal  wall. 

Downward  pressure  of  the  pelvic  organs  with  symptoms  is  sometimes  caused 
by  ascites  and  by  overlying  ovarian  tumors.  The  latter,  however,  unless 
adherent  or  incarcerated,  usually  ride  high  in  the  abdomen  and  give  httle 
pain. 

The  symptoms  arising  from  relaxed  supports,  with  resultant  misplacement 
and  descent  of  the  organs,  are  not  always  those  of  actual  pain,  but  rather  of 
-discomfort.  The  sensation  is  usually  described  as  "bearing-down  feelings," 
and  is  invariably  associated  with  fatigue.  A  large  percentage  of  the  cases,  but 
not  all,  have  sacral  backache.  These  symptoms  are  present  in  an  exaggerated 
degree  in  cases  of  prolapse  following  hysterectomy,  where,  in  finishing  the  opera- 
tion, the  surgeon  has  not  properly  suspended  the  vagina. 

As  is  frequently  emphasized  in  this  book,  pelvic  pressure  symptoms  are  of 
the  utmost  importance  in  their  relation  to  the  general  organism  of  the  patient 
and  especially  to  the  nervous  system. 

Pain  in  the  side  is  a  not  infrequent  accompaniment  of  prolapse,  and  is  usually 
referred  to  the  ovaries.  In  the  absence  of  adhesions  or  disease  of  the  tubes, 
these  so-called  ovarian  pains,  as  a  rule,  actually  arise  from  a  congested  varicose 
condition  of  the  veins  of  the  broad  hgaments.  This  congestion  produces  a  dull, 
constant  ache  similar  to  that  experienced  by  men  who  suffer  from  varicocele. 

Backache  as  a  symptom  of  backward  displacement  of  the  uterus  has  been  a 
subject  of  much  debate.  On  account  of  the  fact  that  many  serious  affections 
of  the  pelvis,  including  extreme  retroflexion  and  procidentia,  are  without  back- 
ache, it  is  believed  by  some  that  it  is  not  a  symptom  of  retroversion.  Those 
who  take  this  view  also  point  to  the  fact  that  no  satisfactory  explanation  has 
yet  been  given  as  to  the  exact  cause  of  the  backache.  There  is,  however,  indis- 
putable evidence  that  in  a  large  percentage  of  cases  retroposition  of  the  uterus 
is  definitely  associated  with  backache  and  that  the  retroposition  in  some  way 
causes  the  backache. 

It  is  very  important  to  note  that  the  backache  caused  by  malposition  of 
the  uterus  is  always  sacral  or  very  low  lumbar,  and  is  always  central.  Back- 
aches  above  this  region  have  no  relation  to  pelvic  disease  except  so  far  as 
they  may  be  the  result  of  a  general  bodily  weakness  that  has  its  origin  in  some 
pelvic  affection.  In  the  same  way,  pain  between  the  shoulder-blades,  pains  in 
the  trapezius  muscles,  or  in  the  back  of  the  neck  and  headaches  bear  only  a 
secondary  relationship  to  pelvic  disease.  The  sacral  backache  from  retroversion 
does  not  differ  greatly  in  character  from  several  orthopedic  conditions  of  this 
region,  and  from  these  it  must  always  be  carefully  distinguished^  Sacral  back- 
ache may  also  be  the  result  of  pelvic  inflammatory  disease  with  peritoneal 
adhesions  of  the  posterior  pelvic  wall. 

Cancer  of  the  cervix  in  its  later  stages  causes  an  excruciating  backache,  but 
it  is  usually  one  sided  and  extends  down  into  the  gluteal  and  sciatic  region.   This 


580  GYNECOLOGY 

pain  comes  only  after  extension  of  the  disease  into  the  parametrium  and 
regional  lymph-glands,  and  is  always  an  indication  of  an  advanced  stage  of 
the  disease. 

It  has  been  said  that  fibroids  are  not  inherently  painful  unless  inflamed, 
adherent,  or  incarcerated.  An  exception  to  this  is  the  occasional  occurrence 
of  pain  from  interstitial  fibroids.  This  pain  is  characterized  by  a  monthly 
periodicity,  having  usually  a  definite  relationship  to  the  menstrual  periods.  It 
is  intermenstrual  in  its  occurrence,  and  usually  appears  from  a  week  to  ten 
days  before  catamenia.  The  pain  is  referred  rather  definitely  to  the  uterine 
regioTi  and  resembles  in  character  that  of  dysmenorrhea.  Fibroids  that  pro- 
duce this  phenomenon  are  usually  of  small  or  moderate  size  and  intramural  in 
position.  Sometimes  the  pain  from  these  tumors  is  sporadic,  coming  on  without 
warning,  lasting  several  hours,  and  then  disappearing  for  an  indefinite  period. 

A  special  type  of  pain  frequently  seen  in  gynecologic  patients  is  one  that 
begins  in  the  loins,  extending  backward  into  the  lumbar  region  and  forward  into 
the  lower  abdomen.  It  is  associated  with  general  fatigue.  Many  of  these 
patients  are  individuals  of  deficient  muscular  power  who  have  gained  weight 
rapidly.  The  pain  is  due  to  the  dragging  weight  of  a  heavy  abdominal  wall  on 
the  muscles  of  the  lateral  abdomen  and  back,  and  can  often  be  relieved  com- 
pletely by  a  properly  fitting  corset  or  abdominal  support.  If,  in  addition  to  the 
accumulation  of  fat,  there  also  exists  a  diastasis  of  the  abdominal  recti  muscles, 
the  symptoms  are  much  more  marked  and  may  necessitate  an  operation. 

Another  form  of  pain  observed  very  frequently  in  women  is  that  referred  to 
the  coccyx  and  termed  coccygodynia.  This  pain  is  often  severe  and  may  be 
disabling.  The  causes  of  coccygodynia  are  usually  referable  to  some  trauma 
of  the  coccyx,  of  which  the  most  common  are  fractures  or  dislocations  from 
falls  or  from  unskilful  instrumentation  at  childbirth.  The  tip  of  the  coccyx 
may  by  such  injuries  be  displaced  into  such  a  position  that  it  is  continually 
exposed  to  shght  traumatism,  especially  when  the  patient  is  sitting.  The 
condition  if  severe  may  require  surgical  removal  of  the  coccyx. 

In  many  instances  the  pain  is  the  result  not  of  a  serious  injury  to  the  coccyx, 
but  to  its  anatomic  structure,  by  which  the  tip  is  exposed  to  constant  trauma- 
tism while  the  patient  is  in  the  sitting  posture.  Faulty  positions  in  sitting  may 
bring  about  a  like  result  even  when  the  anatomy  of  the  coccyx  is  entirely  nor- 
mal. 

Sometimes  coccygodynia  is  regarded  as  a  purely  nervous  manifestation. 
It  is  probable  that  in  most  cases  the  pain  is  actual,  though  it  may  be  overvalued 
in  the  patient's  mind. 

The  pains*  of  menstruation  are  dwelt  on  at  length  in  the  section  on  Dysmen- 
orrhea, to  which  the  reader  is  referred.  It  should,  however,  be  emphasized  here 
that  in  general  the  pains  of  pelvic  disease,  from  whatever  source,  are  usually 
aggravated  during  the  period  of  menstrual  congestion.  This  is  notably  true  of 
pains  resulting  from  immobihzed  organs  like  adherent  adnexa,  incarcerated 


GENERAL   SYMPTOMATOLOGY   IN    GYNECOLOGY  581 

tumors,  etc.,  or  from  mild  inflammatory  processes  like  chronic  appendicitis  or 
catarrhal  salpingitis. 

The  cramp-like  pains  of  essential  dysmenorrhea  are  to  be  regarded  as  repre- 
senting the  symptoms  of  a  special  disease. 

Painful  micturition  is  an  important  symptom  in  the  treatment  of  gyneco- 
logic diseases.  A  sudden  onset  of  painful  burning  urination  is  characteristic  of 
acute  gonorrheal  urethritis,  though  by  no  means  a  constant  symptom  of  the 
disease.  Pain  on  micturition  following  pelvic  operations  usually  indicates  an 
inflammation  of  the  bladder  as  the  result  of  catheterization  or  traumatism  to  the 
bladder,  or  incidental  infection.  Later  in  the  course  of  a  convalescence  from 
surgical  operation  it  may  indicate  the  presence  of  a  pyelitis.  Urinary  discom- 
fort, especially  in  elderly  patients,  often  signifies  a  urethral  caruncle,  or  pro- 
lapse of  the  urethral  mucous  membrane,  or  the  irritation  due  to  senile  changes 
in  the  lining  of  the  bladder  and  urethra.  Long-continued  urinary  irritability 
is  indicative  of  the  various  chronic  inflammations  of  the  urinary  tract. 

Pain  on  defecation  suggests  hemorrhoids,  anal  fissure,  or  anal  fistula,  and 
sometimes  the  involvement  of  the  rectum  by  pelvic  growths. 

Pain  in  the  legs  is  a  common  and  often  baffling  symptom  in  gynecologic 
patients.  In  the  case  of  extensive  mahgnant  disease  of  the  pelvis  or  of  large 
incarcerated  tumors  the  pain  is  sufficiently  well  accounted  for  by  pressure  on 
the  great  nerve-trunks.  In  minor  gynecologic  affections,  however,  such  as  dis- 
placements, small  tumors,  etc.,  the  relationship  between  the  disease  and  the 
pain  in  the  legs  is  less  obvious.  Often  it  may  be  traced  to  some  orthopedic 
condition  of  muscle  strain  in  which  the  pelvic  trouble  plays  only  a  contributory 
part  in  lessening  the  general  tonal  resistance  of  the  patient.  During  the  con- 
valescence from  gynecologic  operations  pain  in  the  calf  of  the  leg  or  along  the 
inner  side  of  the  thigh  or  in  the  groin  should  give  warning  at  once  of  the  pos- 
sible presence  of  phlebitis,  one  of  the  most  troublesome  of  surgical  comphca- 
tions. 

The  subject  of  pain  in  its  relation  to  gynecology  is  almost  limitless,  and  the 
examples  here  given  must  be  considered  not  as  having  exhausted  the  theme,  but 
as  being  those  of  chief  clinical  importance. 


PART    III 

OPERATIVE   GYNECOLOGY 


OPERATIONS   ON  THE  VULVA 
VULVECTOMY 

The  indications  for  removal  of  the  vulva  are  most  commonly  cancer,  krau- 
rosis, tuberculosis,  elephantiasis,  and  esthiomene. 


Fig.  212.- — Vulvectomy.- 
The  double  lines  show  the  position  of  the  initial  incisions.     The  area  included  between  these  lines  is  to 

be  completely  dissected  away. 

582 


OPERATIONS    ON   THE   VULVA 


583 


The  operation  is  not  a  difficult  one,  but  requires  special  attention  to  coap- 
tation of  the  wound  edges  in  order  to  safeguard  against  the  predisposition  which 
large  wounds  of  the  vulva  have  to  sepsis. 

An  oval  incision  is  made  about  the  entire  vulva  external  to  the  diseased  tissue, 
extending  from  above  the  chtoris  to  a  point  between  the  fourchette  and  the 


anus. 


V>lP.bxCvUV5 


Fig.  213.- — Vulvectomy. 
Closure  of  the  wound. 


A  second  circular  incision  is  then  made  about  the  vaginal  orifice  and  meatus 
urinarius,  special  care  being  taken  to  leave  as  wide  a  margin  about  the  meatus 
as  the  exigencies  of  the  case  will  permit.  The  structures  hdng  between  these 
two  incisions  are  dissected  away  in  one  piece,  the  depth  of  the  incision  depend- 
ing on  the  nature  of  the  disease  for  which  the  operation  is  being  done.  There 
is  always  considerable  hemorrhage,  especially  in  the  region  about  the  clitoris. 
As  the  vessels  are  apt  to  retract  to  a  position  troublesome  to  reach,  it  is  advisable 
to  control  each  spurting  vessel  as  soon  as  it  appears.  The  wound  is  closed  in 
the  form  of  a  racquet,  the  upper  edges  of  the  outer  wound  being  approximated 


584 


GYNECOLOGY 


from  side  to  side  down  to  the  point  of  the  wound  just  above  the  meatus.  At 
this  point  the  edges  of  the  outer  and  inner  wound  are  approximated. 

Sometimes  the  excision  of  the  vulva  is  necessarily  so  extensive  that  various 
plastic  maneuvers  must  be  resorted  to. 

If  the  vaginal  mucous  membrane  cannot  easily  be  approximated  to  the  edge 
of  the  skin  wound,  the  vagina  can  be  freed  for  a  short  distance  and  thus  be 
brought  down  more  easily. 

In  operating  for  cancer  of  the  vulva  it  is  often  necessary  to  make  so  wide  a 
dissection  out  on  the  skin  that  the  method  of  approximation  above  described 
is  not  feasible.  The  classical  plastic  device  for  overcoming  this  difficulty  is  to 
make  a  wide  triangular  incision  with  the  apex  toward  the  thighs.  The  tri- 
angular area  of  skin  included  within  the  lines  of  incision  is  somewhat  loosely 
attached  and  can  easily  be  slid  inward  toward  the  vagina.  The  wound  edges 
can  then  be  approximated. 


Fig.  214. — Basset's  Opeeation  for  Cancee  op  the  Vttlva.     The  Incision. 

Hasset   performs   the   complete   operation   at   one   sitting.     We   recommend  Taussig's    method    of 

dissecting  the  inguinal  regions  first  and  performing  a  vulvectomy  at  a  later  operation. 

SPECIAL   OPERATION   FOR   CANCER   OF   VULVA 

The  best  method  for  operating  on  cancer  of  the  vulva  is  that  recommended 
by  Taussig.  He  divides  the  operation  into  two  stages,  the  first  being  a  dissection 
of  the  two  inguinal  regions,  and  the  second,  performed  sometime  later,  a  removal 


OPERATIONS    ON    THE    VULVA  585 

of  the  primary  cancer  mass.  The  two-stage  operation  is  especially  advisable  be- 
cause it  is  impossible  to  secure  first  intention  healing  from  the  vulvectomy  wound, 
and  if  the  inguinal  regions  have  been  dissected  at  the  same  time  they  are  almost 
sure  to  be  infected  from  the  vulvar  area.  This  results  in  an  enormous  gaping 
wound  which  requires  weeks  of  granulation  and  slow  healing. 

The  dissection  of  the  inguinal  regions  is  carried  out  by  the  Basset  method. 
A  long  inguinal  incision  is  made  as  in  an  operation  for  inguinal  hernia,  the  inci- 
sion being  carried  somewhat  further  toward  the  vulva  so  as  to  allow  for  wide 
retraction  of  the  skin.  The  aponeurosis  of  the  external  obHque  is  divided  as  in 
a  hernia  operation  and  the  round  ligament  exposed  from  the  external  to  the 


Fig.  215. — Dissection  of  the  Inguinal  Region  for  Cancer  of  the  Vulva. 
The  round  ligament  is  being  freed,  with  glandular  and  fatty  tissue  attached. 

internal  ring.  The  ligament  is  lifted  out  of  its  bed,  care  being  taken  that  as 
much  of  the  surrounding  fatty  and  cellular  tissue  shall  adhere  to  it  as  possible, 
for  in  this  are  contained  the  lymphatics  of  the  so-called  "upper  pedicle." 

When  the  ligament  has  been  freed  to  the  internal  ring  one  sees  at  this  point 
the  epigastric  artery  and  vein.  The  small  peritoneal  culdesac  which  surrounds 
the  round  Hgament  at  its  entrance  into  the  peritoneal  cavity  is  now  shown. 
Without  opening  the  peritoneum  a  retractor  is  inserted  into  this  culdesac  and 
drawn  strongly  upward,  as  in  Fig.  215.  This  exposes  the  anterior  part  of  the 
internal  iliac  fossa.  All  the  glandular  and  cellular  fatty  tissue  is  then  dissected 
away  from  the  iliac  vessels.    Returning  now  to  the  inner  end  of  the  round  liga- 


586 


GYNECOLOGY 


ment  (i.  e.,  at  the  external  inguinal  ring)  the  cellular  tissue  about  it  is  carefully 
dissected  away  well  down  into  the  upper  part  of  the  labium  majus.  This  com- 
pletes the  dissection  of  the  ''upper  pedicle"  or  chain  of  lymphatics. 

The  next  step  is  to  free  the  lower  chain.  This  consists  in  removing  the  cel- 
lular fatty  tissue  around  the  saphenous  and  femoral  vessels.  The  lower  hp  of 
the  inguinal  incision  is  retracted  downward  to  the  upper  part  of  Scarpa's  tri- 
angle.   If  more  room  is  necessary  a  perpendicular  incision  may  be  made  extend- 


FiG.  216. — Dissection  of  the  I^TGTTINAL  Region  for  Cancee  of  the  Vulva. 
Removal  of  the  upper  chain  of  lymphatics. 


ing  from  the  inguinal  incision  over  Scarpa's  triangle.  One  dissects  then  all  the 
cellular  tissue  from  the  outer  part  of  the  triangle  to  the  labium  majus,  completely 
denuding  the  attachments  of  adductor  longus  and  pectineus  muscles  and  the 
femoral  vessels.  If  the  tissues  have  been  invaded  and  are  voluminous  it  is 
sometimes  necessary  to  tie  and  divide  the  saphenous  vein. 

The  next  step  and  one  of  importance  is  to  remove  the  glandular  tissue  be- 
neath the  femoral  ring.     This  is  accompUshed  by  cutting  across  Poupart's 


OPERATIONS    ON    THE    VULVA 


587 


ligament  (Fig.  217)  and  through  the  femoral  ring  just  inside  the  femoral  vein. 
It  may  even  be  necessary  to  incise  the  bony  attachment  of  Gimbernat's  Hgament. 
When  the  cellular  tissue  of  this  region  has  been  thoroughly  cleaned  out  the  round 
ligament  is  then  tied  and  cut  at  its  point  of  entrance  into  the  peritoneal  cavit}^ 
and  the  ligament  removed  with  the  entire  glandular  fatty  mass  attached.  In 
order  to  make  a  clean  dissection  it  is  necessary  to  tie  the  deep  epigastric  vessels 
close  to  their  point  of  origin. 


Fig.  217. — Dissection  of  the  Ing^tinal  Region  for  Cancer  of  the  Vulva. 

Exposure  of  the  lower  chain  of  lymphatics  by  lifting  up  Poupart's  ligament.     The  red  line  indicates 

the  direction  of  the  incision  which  is  to  divide  Poupart's  ligament.    Exposure  of  the  vessels. 


The  final  step  is  to  restore  the  inguinal  canal.  The  femoral  ring  is  closed  by 
suturing  the  internal  oblique  to  the  femoral  fascia.  Over  this  the  severed  ends 
of  Poupart's  ligament  are  sutured  together. 

Basset  recommends  leaving  in  a  small  drain  leading  from  the  deep  subperi- 
toneal space. 

Both  inguinal  regions  should  be  dissected  in  the  same  radical  manner. 

The  second  stage  of  the  operation  as  described  by  Taussig  is  as  follows : 

''Two  weeks  later  the  inguinal  wounds  have  healed,  usually  by  first  intention. 
We-  now  proceed  to  an  excision  of  the  vulva,  using  neither  scalpel  nor  scissors, 
but  only  the  cautery-knife.    No  attempt  is  made  afterward  to  close  the  entire 


588  GYNECOLOGY      ' 

wound  by  a  dissection  of  flaps.  A  half-dozen  silkworm-gut  sutures  are  used 
merely  to  approximate  the  skin  edges.  Thus  a  considerable  surface  is  left  de- 
nuded. No  dressing  is  kept  on  the  wound  after  the  patient  is  back  in  bed. 
Under  the  open-air  treatment  with  the  occasional  assistance  of  dry  heat  and  the 
frequent  irrigation  of  the  vulvar  wound  with  Dakin's  solution,  rapid  granulation 


Fig.  218. — DibSECxiox  of  the  Inguinal  Region  for  Cancer  of  the  Vvlva. 
Poupart's  ligament  has  been  divided.     The  upper  and  lower  chains  of  glands  are  being  removed 


en  masse. 


is  obtained  and  hone  of  the  necrosis  and  infection  that  otherwise  is  usually  as- 
sociated with  extensive  vulvar  excisions  appears." 

OPERATIONS    ON   BARTHOLIN'S    GLANDS 

Very  acute  abscesses  of  Barthohn's  glands  sometimes  require  incision  and 
evacuation  of  the  pus.  The  incision  in  this  case  should  always  be  made  through 
the  skin  on  the  outer  aspect  of  the  enlarged  gland  rather  than  through  the 
modified  membrane  on  the  vaginal  side.  After  subsidence  of  the  inflammatory 
process  the  gland  should  always  be  removed  by  a  radical  dissection,  as  other- 
wise it  is  almost  sure  to  give  trouble  later,  either  as  a  recurrent  abscess  or  in 
the  form  of  a  cyst.     Many  of  the  abscesses  of  Bartholin's  glands  when  the  in- 


OPERATIONS    ON    THE    VULVA 


589 


flammatory  process  is  not  violently  acute  can  be  excised  without  preliminary 
incision,  the  decision  as  to  this  point  being  determined  by  the  amount  of  infiltra- 
tion or  involvement  of  the  surrounding  tissues. 

Cj^sts  of  Bartholin's  glands,  even  when  small,  should  always  be  radically 
excised,  otherwise  they  are  sure  to  recur. 


|M\ 


'Jk(K.V^ 


N>^  v?6Ya\><t?> 


Fig.  219. — Dissection  of  Bartholin's  Gland  for 
Cyst  or  Abscess. 
The  incision  is  made  through  the  skin  outside  of 
the  labium  minus.  The  cystic  gland  is  dissected  out 
entire  with  blunt-pointed  scissors.  In  order  to 
avoid  rupturing  the  cyst  the  dissection  is  carried 
out  on  the  outer  side  first,  the  region  of  the  duct 
being  dissected  last. 


Fig.  220.  —  Excison  of  Bartholin's 
Gland. 
The  wound  external  to  the  labium 
minus  is  closed  with  deep  silkworm-gut 
sutures.  A  small  rubber  drain  is  placed 
through  a  stab-wound,  to  be  removed  in 
thirty-six  to  forty-eight  hours,  or  later  if  an 
abscess  has  been  exsected. 


The  complete  operations  for  both  abscess  and  cyst  are  practically  identical. 
The  patient  should  be  fully  anesthetized,  for  the  dissection  must  alwaj^s  be 
carried  deeply  into  the  tissues,  and  there  is,  as  a  rule,  troublesome  bleeding. 
The  incision  is  made  on  the  outer  surface  of  the  swelling  through  the  skin.  An 
attempt  is  then  made  to  dissect  out  the  capsule  of  the  abscess  or  cyst,  the  outer 
portion  embedded  beneath  the  skin  being  treated  first.  The  dissection  is 
gradually  brought  around  toward  the  inner  side,  where  it  becomes  more  diffi- 


590  GYNECOLOGY 

cult  on  account  of  the  adherence  of  the  thin  membrane  of  the  inner  side  of  the 
labium  minus.  The  area  of  the  duct  is  approached  last,  and  as  the  dissection 
is  carried  across  this  portion  the  tumor  usually  collapses  and  discharges  its  con- 
tents. It  is  not  always  possible  to  enucleate  the  entire  tumor  without  ruptur- 
ing the  capsule  before  crossing  the  duct;  nevertheless,  if  this  can  be  done,  the 
results  of  the  operation  are  much  more  satisfactory.  If  the  capsule  has  col- 
lapsed it  must  be  removed  from  the  depth  of  the  wound  in  ragged  shreds,  rem- 
nants of  which  if  left  behind  are  liable  to  be  the  source  of  a  future  recurrence. 

In  dissecting  out  a  fresh  gonorrheal  abscess  it  should  be  remembered  that 
the  pus  is  often  under  considerable  tension.  If  the  abscess  is  accidentally  rup- 
tured the  eyes  of  the  operator,  which  are  necessarily  in  a  position  near  the  field 
of  operation,  are  in  much  danger  of  infection  from  the  spurting  pus. 

Before  closing  the  wound  great  care  should  be  taken  to  stop  all  the  hemor- 
jhage  with  ligatures  of  fine  catgut.  If  the  bleeding  cannot  be  controlled  in  this 
way,  deep  sutures  may  be  taken  in  the  bleeding  tissues.  The  dead  space  left 
by  removal  of  the  tumor  is  closed  for  the  most  part  by  buried  deep  sutures. 
A  small  drain  of  folded  rubber  tissue  is  left  in  the  bed  of  the  wound  leading  to 
a  small  stab-wound  to  one  side  of  and  below  the  original  incision.  The  main 
wound  is  closed  with  silkworm-gut  sutures  deeply  placed,  the  ends  of  which 
are  shotted. 


OPERATIONS   ON  THE   CERVIX 


DILATATION  OF  THE  CERVIX 


Dilatation  of  the  cervical  canal  is  performed  as  a  therapeutic  measure  for 
sterility  and  dysmenorrhea,  and  as  a  preliminary  step  to  curetage  of  the  body 
of  the  uterus  and  repair  of  the  cervix. 

With  the  patient  in  the  perineal  position,  the  anterior  Hp  of  the  cervix  is 
grasped  in  the  middle  by  a  pair  of  double  hooks  (or  bullet  forceps).  Enough 
tissue  should  be  included  in  the  double  hooks  to  prevent  their  tearing  out  and 
causing  a  laceration. 

The  best  instrument  is  that  devised  by  Cullen,  the  hooks  of  which  are  mouse- 
toothed,  and  by  their  firmer  hold  on  the  tissues  cause  less  tearing  than  do  the 
ordinary  so-called  bullet  forceps. 

The  cervix  is  drawn  gently  down  toward  the  vaginal  introitus.  Strong 
traction  should  be  avoided.  Dilatation  of  the  non-pregnant  uterus  is  most 
safely  carried  out  with  Hanks'  graduated  dilators.  It  is  best  if  possible  to 
secure  a  set  of  old-fashioned  dilators  which  have  a  short  thrust  with  only  a 
shght  angle.  (The  dilators  usually  sold  are  too  long  and  too  sharply  bent.) 
The  first  dilator  should  be  passed  with  extreme  care  in  all  cases,  for  deviations 
or  angulations  of  the  canal,  or  obstructions  from  stenosis  or  growths,  may 
deflect  the  point  of  the  instrument  into  and  through  the  uterine  tissue.  In 
certain  conchtions  of  atony  of  the  uterus,  more  especially  such  as  exist  after  the 
menopause  or  during  gestation,  an  instrument  may  perforate  the  uterine  wall 
with  almost  inappreciable  resistance. 

If  the  first  dilator  does  not  discover  the  direction  of  the  canal  at  once,  a 
fine  probe  should  be  used.  When  the  direction  of  the  canal  has  been  estab- 
hshed  the  successive  sizes  of  the  dilators  are  used  until  the  last  has  been  passed. 
If  greater  or  more  prolonged  dilatation  is  desired,  as  in  the  treatment  of  dys- 
menorrhea and  steriHty  or  of  retained  products  of  conception,  Goodell  dilators 
may  then  be  used.  These  must  be  handled  with  care,  as  it  is  an  easy  matter 
to  split  the  side  of  the  cervix  with  them  and  cause  a  dangerous  hemorrhage.  If 
the  dilatation  is  being  done  for  exploration  or  curetage  of  the  endometrium,  it 
need  not  be  carried  beyond  the  passage  of  the  largest  Hanks'  dilator. 

The  next  step  is  to  ascertain  the  depth  of  the  uterus,  and  this  is  done  with 
a  measured  uterine  sound.  This  is  also  a  dangerous  instrument,  and  one  which 
most  often  is  responsible  for  perforation  of  the  uterine  wall.  In  order  to  avoid 
this  accident  the  sound  before  being  passed  should  be  bent  to  the  same  angle 
as  the  dilators.  In  passing  it  no  more  pressure  should  be  exerted  than  is  made 
by  the  friction  of  resting  it  on  the  forefinger. 

591 


592  GYNECOLOGY 

Sometimes  a  cervix  is  difficult  to  dilate,  as  occurs,  for  example,  in  the  hypo- 
plastic anteflexed  type  of  uterus,  where  there  is  a  dense  band  of  connective  tissue 
at  the  internal  os.  The  difficulty  of  passing  the  sound  must  be  met  by  strong 
countertraction  on  the  double  hooks  in  the  anterior  lip  of  the  cervix,  and  may 
result  in  lacerating  the  tissue.  If  such  a  laceration  occurs  it  should  be  repaired 
with  fine  catgut,  for  if  neglected  the  wound  may  become  infected  and  cause  a 
long-standing  and  intractable  cervicitis.  In  order  to  avoid  the  accident  of 
lacerating  the  cervical  lip  when  it  is  found  that  the  dilatation  is  going  to  be 
difficult,  two  pairs  of  double  hooks  may  be  used  inserted  each  on  one  side  of 
the  cervix.  If  laceration  takes  places  less  injury  is  done,  as  the  wound  does  not 
communicate  with  the  mucous  membrane. 

CURETAGE 

Since  our  knowledge  of  the  physiologic  and  pathologic  processes  of  the 
uterine  mucosa  has  been  put  on  a  new  scientific  basis  the  use  of  the  curet  is 
much  less  frequent  than  formerly. 

As  a  curative  agent,  its  principal  function  is  for  the  removal  of  products  of 
conception  that  cannot  be  extracted  in  any  other  way,  and  occasionally  in 
some  cases  of  hypertrophy  or  chronic  inflammation  of  the  endometrium  and 
for  chronic  endocervicitis. 

Its  chief  use  is  for  the  removal  of  endometrial  tissue  for  the  purpose  of 
microscopic  examination. 

After  dilatation  of  the  cervix  and  passage  of  the  sound  to  determine  the 
depth  of  the  uterus,  it  is  best  to  explore  the  uterine  canal  next  with  a  pair  of 
placenta  forceps.  These  can  now  be  used  safely  because  the  direction  and  depth 
of  the  canal  is  known.  The  object  of  the  placenta  forceps  is  to  discover  and 
remove  polypoid  growths  which  may  escape  detection  with  the  curet. 

The  curet  is  passed  into  the  canal  in  the  same  manner  as  that  described  for 
the  sound.  It  should  not  be  bent  at  an  angle  sharper  than  that  of  the  dilators 
unless  it  is  being  used  to  remove  some  resistant  material  like  that  of  adherent 
placental  tissue.  If  the  object  of  the  curetage  is  the  removal  of  hypertrophic 
mucosa  the  entire  uterine  canal  is  thoroughly  scraped  with  a  sharp  curet  until 
everywhere  the  sharp  scratch  of  the  submucosa,  the  so-called  cri  uterine,  can 
be  heard.  Each  time  the  curet  is  carried  into  the  uterine  canal  it  should  be 
passed  lightly  on  the  finger,  but  it  may  be  drawn  out  vigorously. 

If  the  object  of  the  curetment  is  the  removal  of  fetal  tissue,  it  is  best  to  use 
a  blunt  wire  curet,  especially  if  the  retained  tissues  are  infected.  The  deep 
scarification  of  the  uterine  canal,  under  such  circumstances,  may  carry  the  in- 
fection into  fresh  lymph-channels  and  encourage  or  set  up  a  dangerous  puer- 
peral infection.  If  in  the  case  of  retained  products  of  conception  it  is  difficult 
to  remove  all  the  contents  of  the  uterus,  it  is  better  not  to  err  on  the  side  of  being 
too  thorough,  for  the  danger  of  perforating  the  uterus  or  of  spreading  infection 


OPERATIONS    ON    THE    CERVIX  593 

is  greater  than  that  of  leaving  in  portions  of  fetal  tissue,  which  are  usually  ex- 
pelled spontaneously.  This  may  occasionally  require  a  later  curetment,  when 
the  uterus  is  less  liable  to  infection  or  perforation. 

When  the  curetage  is  being  employed  for  diagnosis  a  small  sharp  curet  is 
used,  which  explores  every  part  of  the  uterine  canal.  If  the  tissue  removed  is 
suggestive  of  malignancy,  the  curet  is  purposelj^  carried  deep  into  the  uterine 
wall  in  order  to  be  able  to  tell  by  microscopic  examination  whether  or  not  the 
disease  has  invaded  the  myometrium.  In  cureting  for  diagnosis  the  placenta 
forceps  must  always  be  used  in  order  not  to  miss  any  polypoid  growths. 

Curetage  of  the  cervix  for  endocervicitis  should  be  done  with  a  small,  very 
sharp  curet,  and  the  cureting  should  be  confined  to  the  cervical  canal,  for  if  the 
fundus  is  included  there  is  danger  of  spreading  the  infection  of  the  endocervical 
glands. 

After  cureting  the  endometrium  no  further  treatment  is  usually  necessary, 
it  being  important  to  avoid  intra-uterine  douches  and  chemical  applications. 
If  there  is  severe  bleeding,  it  may,  under  rare  circumstances,  be  necessary  to 
pack  the  uterus  with  sterile  gauze,  though  such  bleeding  can  usually  be  con- 
trolled by  packing  the  vagina  tightly  against  the  uterine  vessels. 

If  it  seems  likely  that  bits  of  tissue  have  been  left  in  the  uterine  cavity,  these 
may  be  wiped  out  with  a  strip  of  gauze  carried,  preferably,  on  a  Burrage  tampon 
extractor.  It  should  be  remembered,  however,  that  the  uterus  is  frequently 
perforated  by  this  wiping-out  process. 

Curetment  for  cancer  of  the  cervix  is  best  done  with  a  large,  comparatively 
sharp  curet,  which,  however,  must  be  used  with  great  care  when  in  proximity 
to  the  bladder  or  posterior  culdesac,  or  the  uterine  vessels. 

Cases  for  curetage  should  always  be  subjected  to  a  thorough  surgical  prepara- 
tion, and  should,  with  few  exceptions,  be  anesthetized.  If  patients  are  properly 
prepared,  and  the  operation  done  under  antiseptic  precautions,  simple  puncture 
of  the  uterus  ordinarily  does  no  harm,  and  it  is  usually  not  necessary  to  sew  up 
the  wound  through  a  laparatomy  incision.  The  patient  should,  however,  be 
watched  carefully  for  possible  hemorrhage. 

Larger  wounds,  such  as  are  made  b}'  the  curet  or  placenta  forceps,  especially 
in  removing  fetal  tissue,  may  allow  the  gut  to  prolapse  into  the  uterine  canal. 

Perforation  of  the  posterior  culdesac  made  while  cureting  cancer  of  the 
cervix  is  almost  inevitably  followed  bj^  fatal  peritonitis. 

TRACHELOPLASTY 

Repair  of  the  cervix  is  indicated  in  conditions  of  erosion,  eversion,  and 
inflammation,  and  is  intended  to  restore  the  organ  as  nearly  as  possible  to  its 
normal  appearance  and  tissue  condition.  Most  operations  for  repair  of  the 
cervix  are  based  on  the  operation  originally  suggested  by  Einmet.  The  technic 
of  the  operation  is  as  follows : 

38 


594 


GYNECOLOGY 


With  the  patient  in  the  perineal  position,  dilatation  of  the  cervix  is  first  per- 
formed in  order  to  make  the  tissue  softer  and  more  pliable  and  to  give  more 
room  for  the  passage  of  ligatures.  The  anterior  and  posterior  lips  of  the  cervix 
are  grasped  each  with  double  hooks  placed  exactly  in  the  middle  line,  as  indi- 
cated by  the  central  raphe,  from  which  radiate  the  branching  folds  of  the  cervical 
mucosa  (arbor  vitse).  The  double  hooks  are  then  brought  closely  together  so 
as  to  approximate  the  two  cervical  lips.  In  cases  of  laceration  this  gives  an 
accurate  idea  as  to  whether  the  cervix  has  been  torn  on  one  or  both  sides.  .It 
is  somewhat  more  common  to  find  that  the  tear  is  unilateral,  and  that  the  repair 
need  be  carried  out  only  on  one  side. 


This  point  is  emphasized  because  the  beginner  is  apt  to  place  the  traction  forceps  midway 
between  the  ends  of  the  tear  and  denude  on  each  side  of  the  forceps,  instead  of  placing  the 
forceps  in  the  midline  of  the  cervix  and  denuding  only  where  the  tear  indicates.  If  the  latter 
method  of  technic  is  not  carried  out  the  operation  will  result  in  a  crooked  canal  which  is  apt 
later  to  cause  either  an  atresia  of  the  lumen  or  a  fistulous  opening  in  one  end  of  the  wound. 


Fig.  221. — Tracheloplasty.     Unilateral  Tear. 
Heart-shaped  outline  of  the  area  to  be  denuded. 

When  the  location  of  the  tear  or  tears  has  been  definitely  made,  the  limit  of 
the  denudation  at  the  os  is  marked  with  the  scalpel  on  one  or  both  sides  of  the 
traction  forceps.  In  marking  these  points  it  must  be  borne  in  mind  that  the 
exit  of  the  new  canal  must  be  funnel  shaped,  so  that  it  is  better  to  err  on  the 
side  of  getting  it  too  wide  than  too  narrow,  otherwise  there  is  danger  of  atresia 
in  later  life  when  the  cervix  becomes  atrophied. 

These  important  landmarks  having  been  made,  the  lips  of  the  cervix  are 
drawn  widely  apart  and  the  area  of  denudation  outlined  with  the  scalpel.  This 
area  simply  includes  the  sides  and  angle  of  the  laceration  (Fig.  221).     The 


OPERATIONS    ON    THE    CERVIX 


595 


outside  edge  is  a  continuous  line  from  the  mark  on  che  anterior  lip  to  that  of 
the  posterior  hp  in  the  smooth  vaginal  portion  of  the  cervical  membrane;  the 
inside  edge  constitutes  a  hne  between  points  in  the  rough  endocervical  mucous 
membrane.  The  width  of  the  denudation  area  is  usually  about  f  inch,  corre- 
sponding to  the  natural  thickness  of  the  cervical  wall.  It  is  important  that  the 
figure  of  denudation  be  symmetrically  drawn  on  the  two  lips,  so  that  when  they 
are  approximated  for  suture  there  will  be  perfect  coaptation  of  the  wound 
edges.     The  denudation  of  the  marked-out  area  is  made  with  a  small  scalpel, 


SvjtovcUo.i 


Fig.  222. — Tracheloplasty. 
Unilateral  denudation  of  cervix  and  placing  of  stitches. 

beginning  from  the  mucous  membrane,  and  should  be  carried  out  so  that  the 
tissue  to  be  removed  from  both  lips  and  the  angle  between  them  is  taken  off  in 
one  piece.  If  there  is  a  great  deal  of  scar-tissue  beneath  the  denuded  surface 
it  may  be  dissected  out  in  small  wedge-shaped  pieces. 

When  the  laceration  is  deep,  denudation  of  the  angle  usually  causes  some 
bleeding  from  the  cervical  artery.  This  should  be  controlled  by  a  •  ligature 
passed  into  the  tissue  with  a  needle  before  the  stitches  are  placed,  for  if  this 
bleeding  is  neglected  it  may  give  trouble  during  the  convalescence,  sometimes 


596  GYNECOLOGY 

requiring  a  secondary  operation.     If  there  are  several  lacerations,  they  should 
be  denuded  before  putting  in  the  stitches. 

The  placing  of  the  sutures  may  cause  considerable  embarrassment  on  the 
part  of  the  operator  if  the  laceration  is  a  deep  one,  or  if  the  cervix  cannot  be 
drawn  well  down  to  the  introitus.  This  difficulty  may,  however,  always  be 
avoided  by  the  proper  use  of  special  needles. 

The  best  needle  is  that  originally  devised  by  Emmet.  It  has  a  slight  curve,  and  can  be 
forced  through  the  tough  fibrous  tissue  of  the  cervix  without  danger  of  breaking,  an  accident 
which  may  be  very  troublesome.  ^ 

The  placing  of  the  first  suture  is  the  most  important.  If  the  angle  is  diffi- 
cult to  reach,  it  is  best  to  use  a  ''double  header"  suture — i.  e.,  one  with  a  needle 
on  each  end.  The  first  needle  is  passed  from  within  outward  on  one  lip,  so  that 
it  will  issue  well  beyond  the  angle  of  denudation  (Fig.  222).     The  other  needle 


Fig.  223. — Unilateral  Teacheloplasty  Fig.  224. — Lacerated  Cervix  with  One  Lip 

Completed.  Longer  than  the  Other. 

is  then  passed  in  a  similar  way  in  the  other  fip,  and  the  two  ends  are  fastened 
in  a  clamp.  By  passing  the  suture  in  this  way  no  difficulty  is  encountered,  and 
it  is  placed  so  high  beyond  the  angle  that  when  tied  it  serves  to  control  any 
cervical  vessels  that  might  otherwise  bleed  later.  The  other  sutures  are  then 
placed  in  like  manner,  the  ''double  header"  no  longer  being  necessary  after 
the  first  one  or  two  stitches.  It  is  best  to  clamp  the  ends  of  the  sutures  without 
tying  until  they  have  all  been  placed.  Sutures  are  then  placed  on  the  denuded 
area  of  the  other  side  if  a  double  laceration  is  present.  When  all  the  sutures  are 
in  place  the  traction  forceps  are  removed  and  the  sutures  tied.  The  best  suture 
material  is  No.  1  chromicized  catgut. 

Not  infrequently  one  fip,  usually  the  anterior,  is  longer  than  the  other,  so 
that  the  denuded  areas  do  not  match  when  approximated  (Fig.  224).  If  the 
difference  in  length  is  only  sfight,  the  difficulty  may  be  obviated  by  placing 
a  tenaculum  in  the  side  of  the  longer  fip,  a  short  distance  from  the  angle 
of  denudation,  and  drawing  it  sharply  outward.  This  creates  a  new  angle 
and  makes  the  two  lips  of  equal  length.  One  lip,  however,  may  be  so  much 
longer  than  the  other  that  this  maneuver  will  not  suffice  to  make  their  length 


OPERATIONS    ON    THE    CERVIX 


597 


equal.  In  this  case  the  end  of  the  longer  lip  may  be  amputated  by  a  wedge- 
shaped  incision  and  the  edges  sewed  with  catgut.  In  this  way  the  lips  are 
easily  made  of  equal  length. 


Fig.  225. — Tbacheloplasty. 
Method  of  creating  a  new  angle  when  one  Up  is  longer  than  the  other.     If  this  cannot  be  done 
on  account  of  the  stiffness  of  the  tissues,  a  wedge-shaped  piece  may  be  removed  from  the  end  of  the 
longer  lip. 


Fig.  226 — Tracheloplastt. 
Creating  a  new  angle  when  one  lip  is  longer  than  the  other. 

When  the  hypertrophy  and  elongation  of  one  lip  is  very  marked  the  preceding 
operation  is  not  sufficient  to  equalize  the  two  lips.  It  is  then  necessary  to  ampu- 
tate the  elongated  lip.  This  is  done  by  removing  it  by  a  wedge-shaped  incision 
(Fig.  227).     The  edges  of  the  wound  may  then  be  easily  approximated  by  a  few 


598 


GYNECOLOGY 


interrupted  catgut  sutures  (Fig.  228).  When  the  amputation  wound  has  been 
closed  the  two  hps  are  equal  in  length  and  the  operation  for  the  laceration  is 
carried  out  as  in  the  ordinary  case. 

Sometimes  the  hypertrophy  of  the  submucous  connective  tissue  along  the 
center  of  the  canal  is  so  great  that  the  denuded  areas  of  the  sides  cannot  be 
approximated  without  too  great  tension  on  the  stitches  (Fig.  230).    To  obviate 


Fig.  227. — Tkacheloplasty. 
Amputation  of  an  elongated  lip. 


Fig.  228. — Tkacheloplasty. 

Amputation  of  an   elongated    lip.     Closure   of 

wound. 


Fig.  229. — Tkacheloplasty. 

Amputation    of    an    elongated   lip.     Closure   of 

wound. 


this  a  transverse  wedge  may  be  removed  from  one  or  both  lips,  and  the  edges  of 
the  mucous  membrane  sewed  with  catgut  (Figs.  231,  232).  When  this  is  done 
it  will  be  found  that  the  denuded  areas  can  be  approximated  without  difficulty. 
When  the  tear  is  stellate  there  are  more  than  two  lacerations  and  the  repair 
looks  somewhat  complicated.  By  sewing  up  each  tear  as  above  no  great  difficulty 
is  encountered,  a  smooth  result  depending  on  the  ingenuity  of  the  operator. 


OPERATIONS    ON   THE    CERVIX 


599 


Fig.  230 Ectropion  of  the  Cervical  Mucous  Membrane  After  a  Severe  Bilateral 

Laceration. 


J)^nu6e6  J/rea 


"ff'^.r/i  ov  to 


o . 
ope.t\mo<;, 


Fig.  231. — Tracheloplasty. 

Removal   of    wedge-shaped    piece    from    the    everted 

mucous   membrane.      (Baker's   method.) 


Fig.  232. — Tracheloplasty. 
Baker's  method  of  reducing  redund- 
ant and   everted  mucous  membrane   by 
the  removal  of  wedges. 


AMPUTATION  OF  THE  CERVIX 

The  chief  indication  for  amputation  of  the  cervix  is  in  procidentia,  where 
the  cervix  is  usually  elongated  and  attenuated. 

The  operation  of  amputation  should  not  be  preceded  by  dilatation,  a  pro- 
cedure which  so  stretches  and  thins  out  the  canal  that  it  is  difficult  to  avoid 
tearing  into  it  in  the  process  of  stripping  out  the  cervix.  A  sound  is  first  passed 
to  determine  the  depth  of  the  uterus  and  cervix  and  to  ascertain  approximately 
the  1-vel  of  the  internal  os.  A  sound  is  then  passed  through  the  urethra  into 
the  bladder  fold,  where  it  is  reflected  from  the  cervix.  This  fold  is  usually  found 
on  the  anterior  wall  of  the  cervix  very  near  the  external  os,  and  a  knowledge  of 
its  exact  position  is  very  important. 


600 


GYNECOLOGY 


Traction  hooks  are  then  placed  one  at  each  corner  of  the  tear  and  one  in  the 
middle  of  the  cervix,  including  both  lips  and  sealing  the  opening,  so  as  to  avoid 
the  expulsion  of  any  endocervical  discharge  during  the  operation. 

With  the  cervix  held  out  in  strong  traction  a  circular  incision  is  made  just 
beyond  the  reflection  of  the  bladder  fold.  The  assistant  exercises  counter- 
traction  on  the  vaginal  mucous  membrane,  and  the  circular  dissection  is  carried 
out  with  a  knife  until  the  small  tubular  core  of  the  cervix  is  reached,  great  care 


Fig.  233. — Amputation  of  the  Cervix. 

The  cervix  has  been  drawn  well  out  from  the  vagina.     The  cervix  is  being  circumcised   at^'  (the 

junction  of  the  bladder  with  the  portio  vaginalis. 


being  taken  not  to  injure  the  bladder  fold.  The  fold  of  Douglas'  pouch  on  the 
posterior  wall  of  the  cervix  is  usually  not  in  danger  in  this  dissection,  as  it  is 
attached  higher  up  than  the  bladder.  After  the  core  of  cervix  is  reached  it 
will  be  found  that  the  tissue  of  the  uterine  wall  can  easily  be  stripped  back  from 
it  by  gauze  dissection  (Fig.  233),  the  knife  being  occasionally  necessary  to  sever 


OPERATIONS    ON    THE    CERVIX 


601 


especially  resistant  connective-tissue  fibers.  This  dissection  is  carried  to  within 
a  short  distance  of  the  internal  os,  as  determined  by  the  length  of  the 'cervix  pre- 
viously ascertained.  The  two  traction  forceps,  are  then  inserted  in  the  sides  of 
the  cervical  tube  close  to  the  limit  of  the  dissection,  and  held  by  the  assistants. 
The  cervix  is  drawn  strongly  outward  by  the  remaining  traction  forceps  and  the 


Fig.  234. — Amputation  of  the  Cervix. 
The  elongated  cone-like  cervix  has  been  stripped  out  of  its  bed  and  is  now  ready  for  amputation. 

tubular  core  is  amputated  by  a  wedge-shaped  incision,  so  that  the  uterine  por- 
tion will  be  convex.  This  is  an  important  maneuver,  because  it  leaves  a  con- 
venient stump  for  the  insertion  of  stitches  through  the  cervical  mucous  mem- 
brane— the  stump  being  held  forward  by  the  two  traction  forceps.  If  this 
precaution  is  not  taken,  the  cervical  mucous  membrane  will  retract  sharply 


602 


GYNECOLOGY 


back,  and  be  so  hidden  from  view  that  it  is  difficult  to  place  sutures  in  it.  During 
the  dissection  the  bleeding  may  be  little  or  great,  depending  on  the  amount  of 
congestion  in  the  individual  case.  The  bleeding  points  are  now  tied,  preferably 
with  No.  0  catgut. 

The  placing  of  the  sutures  should  be  carried  out  with  great  precision,  for  it 
is  to  the  exact  approximation  of  the  wound  edges  that  the  operation  owes  its 


ifo.S 


JTo.l     %>.z 


^vCort  ot  Ce-cvix. 


Vl^CS.SCNiCi. 


c^ 


Fig.  235. — Amputation  of  the  Cebvix. 
The  cervix  has  been  amputated  so  that  the  stump  juts  from  the  surrounding  tissue  in  the  form  of 
a  wedge.  Three  sutures  have  been  introduced  into  the  anterior  lip  of  the  cervical  stump  and  contin- 
ued to  the  vaginal  mucous  membrane,  taking  in  a  little  of  the  intervening  tissue.  Three  other  corre- 
sponding sutures  are  next  passed  through  the  posterior  cervical  wall  in  the  same  way.  By  the  tying 
of  these  six  sutures  the  mucous  membrane  of  the  cervical  canal  and  that  of  the  vagina  are  exactly 
approximated.     (See  Fig.  .?37.) 


success.     Inaccurate  coaptation  almost  invariably  results  in  local  sepsis,  with 
sometimes  a  very  marked  constitutional  reaction. 

The  cervical  stump  is  held  in  the  middle  line  by  the  traction  forceps.  Three 
sutures  are  placed  through  the  anterior  lip  of  the  cervical  stump  including  the 
mucous  membrane,  and  carried  to  the  anterior  edge  of  the  vaginal  flap  (Fig.  235). 


OPERATIONS    ON    THE    CERVIX 


603 


Three  sutures  are  then  passed  through  the  posterior  hp  of  the  cervical  hp  to 
the  posterior  edge  of  the  vaginal  flap.  Next  a  suture  is  passed  from  the 
anterior  vaginal  flap  across,  including  the  left  cervical  angle,  and  issuing  from 
the  posterior  flap  at  a  point  directly  opposite  to  that  from  which  it  started. 
The  ends  of  the  suture  are  clamped  and  drawn  strongly  to  the  right,  the  traction 
forceps  being  removed  (Fig.  236).  A  long-pointed  tenaculum  is  then  inserted 
in  the  edge  of  the  vaginal  flap  at  a  point  exactly  between  the  entrance  and  exit 
of  the  last  placed  cross-suture  and  drawn  strongly  outward.     Cross-sutures  are 


V/.'PGKo.^/e,*^ . 


Fig.  236. — Amputation  of  the  Cervix. 
Manner  of  introducing  the  lateral  sutures  so  as  to  secure  exact  approximation.  The  first  suture 
is  drawn  sharply  to  the  opposite  side  and  a  tenaculum  placed  in  the  angle  of  the  vaginal  wound.  The 
sutures  can  then  be  accurately  introduced,  so  as  to  avoid  any  puckering  or  clumsy  coaptation  of  the 
wound  edges.  The  sutures  uniting  the  mucous  membrane  of  the  cervix  and  that  of  the  vagina  (as 
in  Fig.  235),  though  applied  first,  are  omitted  in  this  drawing  for  the  sake  of  clearer  illustration. 


now  placed  from  the  anterior  to  the  posterior  flap,  each  one  including  some  of 
the  loose  paracervical  tissue  to  avoid  leaving  a  dead  space.  The  same  pro- 
cedure is  then  carried  out  on  the  other  side  of  the  cervical  stump.  When  the 
stitches  are  tied  it  will  be  found  that  exact  coaptation  has  been  secured.  By 
employing  this  technic  sepsis  will  rarely  occur  and  scar  formation  or  atresia  of 
the  canal  need  not  be  feared. 

The  operation  just  described  is  a  high  amputation  of  the  cervix.  Low  am- 
putation is  done  in  the  same  way  for  removal  of  the  cervix  when  not  elongated, 
the  dissection  being  carried  up  only  a  short  distance. 


604 


GYNECOLOGY 


Fig.  237. — Amputation  of  the  Cervix. 
Hegar's  method,  showing  the  manner  in  which  the  approximation  sutures  are  introduced.    The 
sutures  on  each  side  are  passed  deeply  into  the  paracervical  tissue  so  as  to  assist  in  controlling  hemor- 
rhage, the  most  important  blood-vessels  lying  in  these  areas. 


Fig.  238. — Amputation  of  the  Cervix. 
Sutures  tied  and  operation  finished. 


SCHRODER'S  OPERATION 

Schroder's  operation  is  used  for  intractable  endocervicitis,  and  is  designed 
■for  the  complete  removal  of  the  endocervical  mucous  membrane. 

The  cervix  is  first  seized  with  two  pairs  of  double  hooks  or  traction  forceps, 
one  on  each  lip  of  the  cervix,  and  drawn  down  to  the  vaginal  introitus.  The 
cervix  is  then  split  on  each  side  with  the  scalpel,  the  incision  being  carried  well 
up  toward  the  internal  os,  in  a  manner  simulating  a  deep  bilateral  laceration. 
Bleeding  points  are  clamped  and  tied.  The  lips  are  then  held  widely  apart  by 
the  traction  forceps.  From  each  lip  a  transverse  wedge-shaped  piece  is  taken, 
including  all  the  mucous  membrane  excepting  a  narrow  margin  near  the  internal 
OS,  into  which  sutures  can  be  placed.     The  shape  of  the  wedge  of  tissue  to  be 


OPERATIONS    ON   THE    CERVIX 


605 


Fig.  239. — Cervicitis  and  E^^)ocERVICITIS,  with  Formation  of  Naeothian  Cysts. 


Fig.  240.^ — Schroder's  Operation  for  Extir-       Fig.  241. — Schroder's  Operation  for  Extir- 


pation OF  THE  EndOCERVIX. 

First  step.     The  cervix  is  being  cut  bilaterally 

to  the  level  of  the  internal  os. 


PATION  of  THE  EndOCERVIX. 

The  bilateral  incision  has  been  made.  The 
mucous  membrane  of  the  posterior  lip  has  been 
removed  and  the  mucous  membrane  of  the  an- 
terior lip  is  being  dissected  in  the  same  manner. 


removed  will  be  understood  by  reference  to  Fig,  241.    The  cervical  mucous 
membrane  of  the  vaginal  portion  of  each  lip  is  approximated  to  the  margin  of 


603 


GYNECOLOGY' 


endocervical  mucous  membrane  by  two  catgut  sutures.     In  approxirriating  these 
edges  the  hps  are  folded  in  on  themselves,  so  that  the  cervical  canal  is  now 


Fig.  242. — Schroder's  Operation  for  Extir- 
pation OF  THE  ENDOCERVIX. 
The  mucosa  has  been  removed  from  both 
lips.  On  the  anterior  lip  the  mucous  membrane 
of  the  cervical  canal  has  been  united  to  that  of 
the  portio  by  three  sutures.  The  same  process 
is  being  repeated  on  the  posterior  lip,  the  middle 
suture  having  been  passed. 


Fig.  243. — Schroder's  Operation  for  Extir- 
pation OF  THE  EndOCERVIX. 
The  mucosa  has  been  removed  and  the  ap- 
proximation of  the  cut  edge  of  the  cervical 
mucous  membrane  to  that  of  the  portio  has 
been  secured  by  the  sutures  on  each  lip.  The 
angles  are  being  denuded,  the  rest  of  the  opera- 
tion being  carried  out  exactly  as  an  Emmet's 
tracheloplasty. 


lined  with  the  epithelial  surface  of  the  vaginal  portion.     Before  tying  the 
sutures  the  traction  forceps  must  be  removed,  but  the  cervix  may  be  still  held 


Fig.  244. — Schroder's  Operation. 
Angles  ready  for  suture. 


Fig.  245. — Schroder's      Operation 

pleted. 


COM- 


down  by  applying  one  of  them  to  the  anterior  wall  of  the  cervix  sufficiently 
high  to  avoid  exerting  any  tension  on  the  stitches.  When  the  anterior  and 
posterior  walls  have  been  folded  in  and  the  stitches  tied  it  will  be  found  that 


OPERATIONS    ON    THE    CERVIX 


607 


the  cut  surfaces  on  the  sides  of  the  cervix  now  present  the  appearance  seen  when 
a  bilateral  laceration  has  been  denuded  and  ready  for  the  placing  of  the  sutures. 
The  sutures  are  then  placed  in  the  manner  described  for  a  tracheloplasty. 

In  passing  the  sutures  which  fold  in  the  cervical  Hps  a  small  full-curved 
needle  should  be  employed,  and  great  care  should  be  exercised  to  avoid  tearing 
through  the  endocervical  mucous  membrane,  for  if  this  happens  it  is  difficult 
afterward  to  place  the  stitch  so  that  it  wih  hold  securely.  The  success  of  the 
operation  depends  very  largely  on  the  skilful  placing  of  these  mucous  membrane 
sutures,  for  if  they  give  way  the  result  is  a  long  and  cicatricial  process  of  healing. 

Schroder's  operation  is  a  radical  but  almost  certain  cure  for  endocervicitis, 
but  it  is  difficult  of  performance  and  should  not  be  attempted  except  by  those 
experienced  in  plastic  surgery,  for  if  improperly  done  the  result  is  a  troublesome 
mutilation  of  the  cervix. 


OPERATIONS   ON  THE  VAGINA 

ANTERIOR  COLPOPLASTY.     (AUTHOR'S  METHOD.) 

The  description  of  this  operation  can  be  understood  only  by  reference  to  the 
accompanying  cuts  and  cUagrams. 


ViVGccvw«.S- 


FiG.  246. — Operation  for  Ctstocele.     (Author's  method.) 
In  order  to  expose  the  cystocele  before  beginning  the  denudation,  tenacula  are  placed  in  the  upper 
angles  of  the  introitus  and  drawn  upward  and  outward.     This  brings  the  cystocele  into  a  convenient 
position  for  operation. 


The  field  of  operation  is  exposed  by  inserting  tenacula  in  the  upper  angles 
of  the  introitus  made  by  the  anterior  fold  of  the  vestibule  with  the  lateral  walls 
of  the  vagina  (Fig.  246).     By  drawing  the  tenacula  outward  the  whole  cysto- 

608 


OPERATIONS    ON   THE   VAGINA 


609 


cele  is  brought  into  full  view.  The  first  step  is  to  map  out  the  area  for  denuda- 
tion by  selecting  and  marking  the  angles  of  the  figure.  The  points  F  and  D 
(Fig.  247)  are  first  chosen  by  picking  up  the  mucous  membrane  with  two  pairs 
of  thumb  forceps  and  drawing  them  together  in  the  middle  line.  The  points 
should  be  selected  so  that  when  approximated  in  front  of  the  cervix  the  cysto- 
cele  is  entirely  reduced  and  the  tension  is  suflScient  to  form  a  sort  of  bridge  in 
front  of  the  cervix,  forcing  it  backward.     By  pinching  the  forceps  together  the 


Fig.  247. — Anterior  Colpoplasty. 

points  are  marked  in  the  mucous  membrane.  The  points  G  and  C  are  next 
selected.  These  are  also  chosen  so  that  when  approximated  in  the  middle 
line  the  anterior  part  of  the  cystocele  will  be  approximated.  These  points, 
G  and  C,  are  always  closer  together  than  F  and  D,  because  the  vagina  should 
not  be  drawn  too  tightly  near  the  introitus.  The  point  E  is  in  the  central  fine, 
just  at  the  reflection  of  the  vaginal  mucous  membrane  from  the  portio  of  the 
cervix.  When  the  points  have  been  carefully  marked,  the  area  included  between 
E,  D,  C,  G,  and  F  is  denuded  with  Emmet's  scissors.     Experience  has  shown 

39 


610 


GYNECOLOGY 


that  this  method  of  denudation  is  safer,  more  rapid,  and  more  satisfactory  than 
removal  of  the  mucous  membrane  by  the  sphtting  of  a  flap.  When  the  area 
has  been  denuded  a  suture  is  first  placed,  entering  the  mucous  membrane  at  D^ 


Fig.  248. — Operation  for  Cystocele.     Anterior  Colpoplastt.     (Author's  method.) 
The  amount  of  cystocele  is  determined  by  folding  the  redundant  wall  in  the  manner  here  depicted. 
By  pressing  the  thumb  forceps  four  landmarks  are  made  in  the  mucous  membrane  which  serve  as  a 
guide  to  the  denudation.     These  four  marks  correspond  to  the  points  A,  B,  C,  and  D  in  the  diagram 
(Fig.  247). 


passing  across  the  cystocele,  and  issuing  at  F.  The  ends  of  the  suture  are  clamped 
and  drawn  sharply  upward  by  the  assistant.  This  approximates  and  brings 
into  easy  reach  the  edges  E-F  and  E-D,  which  are  then  united  by  several  inter- 
rupted sutures. 


OPERATIONS    ON   THE   VAGINA 


611 


The  first  stage  of  the  operation  is  now  completed,  and  should  result  in  reduc- 
ing the  posterior  part  of  the  cystocele  and  drawing  a  tight  bar  of  tissue  across 
the  front  of  the  cervix.  The  second  stage  of  the  operation  is  directed  to  the 
anterior  part  of  the  cystocele  which  includes  the  urethra.  This  portion  is 
usually  protuberant,  though  the  prominence  of  the  tissue  is  often  due  rather  to 
hypertrophy  of  the  vaginal  wall  than  to  hernia  of  the  urethra. 

A  point  A  is  selected  several  centimeters  from  the  urethra,  which  will, 
without  too  great  tension,  meet  the  points  G  and  C  when  brought  together  in 


Fig.  249. — Operation  for  Cystocele.     (Author's  method.) 
Stitches  placed  and  readj-  for  tjing. 

the  middle  line.  The  points  H  and  B  are  determined  by  the  insertion  of  the 
tenacula.  The  area  included  between  G,  H,  A,  B,  and  C  is  then  denuded. 
A  crown  suture  entering  near  the  angle  C,  including  the  angle  A  in  the  manner 
of  a  mattress  suture  and  issuing  at  G,  is  then  passed  and  the  ends  clamped. 
By  draT\dng  this  suture  sharply  to  the  left  the  edges  H-G  and  H-A  are  ap- 
proximated and  sewed  with  interrupted  sutures,  and  by  drawing  the  suture 
sharply  to  the  right  the  edges  A-B  and  B-C  are  united  in  a  like  manner.     The 


612 


GYNECOLOGY 


Fig.  250. — Operation  for  Ctstocele  (Ai^thor's  Method). 
Buried  running  stitch,  implicating  the  bladder  wall,  to  be  used  in  cases  of  marked  cystocele. 
The  stitch  should  be  passed  so  as  to  include  the  fascial  investment  which  lies  between  the  bladder 
and  vaginal  walls. 


OPERATIONS    ON    THE    VAGINA 


613 


crown  suture  is  then  tied,  two  or  three  stitches  placed  between  G  and  F,  and  the 
operation  is  completed. 

By  carrjdng  out  this  technic  the  cystocele  is  reduced  throughout  and  the 
wound  edges  are  all  accurately  approximated. 


Fig.  251. — Oper.\tiox  for  Cystocele.     (Author's  method.) 
Sutures  tied,  operation  completed.     The  anterior  vaginal  wall  should  at  the  finish  of  the  operation 

have  a  concave  contour. 

If  the  c3^stocele  is  very  marked  it  is  a  good  plan  to  enfold  the  bladder  by  a 
row  of  buried  No.  00  catgut  sutures  before  placing  the  main  sutures. 

It  should  be  remembered  that  this  operation,  Hke  all  plastic  operations  on 
the  anterior  wall,  cannot  be  depended  on  of  itself  to  maintain  a  permanent 
reduction  of  the  cystocele  if  there  is  present  at  the  same  time  a  prolapse  of  the 
uterus.  As  prolapse  and  cystocele  usually  go  hand  in  hand,  the  operation  for 
cystocele  is  valuable  chiefly  when  used  in  combination  with  an  appropriate 
suspensory  operation  for  rehef  of  the  prolapse. 


614 


GYNECOLOGY 


OPERATION  FOR  FUNCTIONAL  INCONTINENCE  OF  URINE 

Numerous  operations  have  been  devised  in  times  past  for  functional  incon- 
tinence. One  type  of  operation  is  based  on  the  principle  of  narrowing  the  ex- 
ternal orifice,  another  of  reduplicating  and  folding  in  the  urethra  along  its  entire 


d 


."Bent  Soonbi 


y- 


viounb 


"V^^GrcvOeS- 


FiG.  252. — Kelly's  Operation  for  Functional  Incontinence  of  Urine,  Combined  with  the 

Author's  Anterior  Colpoplasty. 
The  anterior  vaginal  wall  has  been  denuded  as  for  a  cystocele,  except  that  the  corners  of  the 
flaps  have  been  dissected  up  in  the  region  of  the  neck  of  the  bladder  and  of  the  urethra.  The  drawing 
shows  the  method  of  determining  the  position  of  the  neck  of  the  bladder.  A  uterine  sound  is  slightly 
bent  at  the  end  and  introduced  into  the  bladder.  The  neck  of  the  bladder  can  easily  be  perceived  as 
the  end  of  the  sound  passes  it. 


course  (Pawlik,  Duret).  Gersuny  advocated  dissecting  out  the  urethra  and 
twisting  it  so  as  to  narrow  the  canal.  In  still  another  form  of  operation  the 
urethra  is  transplanted  so  that  the  meatus  is  brought  near  the  clitoris  (Albarran, 


OPERATIONS    ON    THE    VAGINA 


615 


Dudley).  In  this  way  the  urethra  is  made  to  describe  a  sharp  bend  around  the 
symphysis.  The  author  has  tried  all  of  these  methods,  and  finds  that,  though 
temporarily  successful,  they  usually  result  in  recurrence  after  a  few  months. 
The  operation  de\dsed  by  Kelly,  however,  produces  a  high  percentage  of  per- 
manent cures.  This  operation  depends  for  its  success'  on  suturing  together  the 
lacerated  or  relaxed  tissues  of  the  sphincter  at  the  neck  of  the  bladder. 

Inasmuch  as  a  considerable  proportion  of  women  with  functional  incontinence 
also  have  a  cystocele,  we  have  successful!}'  combined  Kelly's  operation  with  the 


f^l.^Oxayes  — 


Fig.  253. — Operation  for  Fuxctioxal  Ixcontinence  of  Urine.     Kelly's  Method  Combined 
"mTH  THE  Author's  Operation  of  Anterior  Colpoplastt. 
Sutures  have  been  placed  and  tied,  narro^-ing  the  internal  orifice  of  the  urethra.     Two  linen 
sutures  are  shown  placed  in  the  unjdelding  tissue  at  the  sides  of  the  urethra.     When  these  sutures 
are  tied  a  firm  supporting  bridge  is  created,  guarding  the  first  line  of  sutures. 


author's  anterior  colpoplasty.  The  operation  is  as. follows :  The  anterior  vaginal 
wall  is  denuded  in  exactly  the  same  way  as  in  the  operation  for  c^^stocele  de- 
scribed on  page  609.  When  the  denudation  has  been  completed,  the  urethra 
is  then  dissected  out  with  blunt  curved  dissecting  scissors.  This  leaves  the  flaps 
at  the  upper  part  of  the  operative  field  free.  Tenacula  are  then  inserted  in  the 
three  converging  angles  and  the  flaps  drawn  sharplj'  outward.     In  this  way  the 


616 


GYNECOLOGY 


urethra  at  its  entrance  into  the  bladder  and  the  surrounding  tissue  are  widely 
exposed  to  view  (Fig.  253).  A  uterine  sound,  with  its  point  slightly  bent,  is  now 
introduced  into  the  bladder.  As  the  point  of  the  sound  passes  the  internal 
orifice  of  the  urethra  it  gives  a  slight  but  very  perceptible  jump.  This  point 
is  readily  marked  by  feeling  the  end  of  the  sound  from  the  side  of  the  vaginal 
wound.  By  pressing  backward  on  the  handle  of  the  sound  the  exact  location 
of  the  bladder  neck  can  be  kept  constantly  in  view.     Several  interrupted  sutures 


?!  Gravies- 


Fig.  254. — Kelly's  Operation  for  Incontinence  Combined  with  the  Author's  Anterior  Col- 

POPLASTY.     Operation  Completed. 

of  fine  linen  are  then  passed,  picking  up  ragged  tissues  on  each  side  of  the  urethra 
at  the  level  of  its  entrance  into  the  bladder.  These  sutures  are  tied  in  the 
middle  line,  and  serve  to  compress  the  internal  orifice,  as  can  be  plainly  tested 
by  drawing  out  and  again  inserting  the  bent  sound.  The  sutures  thus  placed 
are  reinforced  by  two  or  three  other  sutures  of  linen,  which  pick  up  firm  unyield- 
ing fibrous  tissue  well  up  on  the  sides  of  the  urethra. 

The  operation  for  cystocele  is  then  continued  in  the  usual  manner,  provision 
being  made  to  give  a  little  extra  tightness  at  the  point  corresponding  to  the 
neck  of  the  bladder.     When  finished  the  appearance  is  like  that  seen  in  Fig.  254. 


OPERATIONS    ON    THE    VAGINA 
ANTERIOR   COLPOPLASTY    (CLARK'S   TECHNIC) 


617 


In  the  operation  of  anterior  colpoplasty  just  described  the  operative  field 
is  exposed  by  simple  denudation  of  the  vaginal  mucous  membrane.  Another 
type  of  operation  for  cystocele  consists  in  separating  completely  the  vaginal 
membrane  from  the  bladder  wall.  Of  these  two  methods  we  prefer  the  former, 
as  it  is  more  rapid  and  involves  less  danger  from  bleeding  or  injury  to  the  bladder 


NVlP.trr- 


Fig.  255. — Antehior  Colpoplasty. 
Initial  incision  of  vaginal  mucous  membrane. 


Fig.  256. — Anterior  Colpoplasty. 
The  mucous  membrane  of  the  vagina  has 
been  incised  and  the  vaginal  and  bladder  walls 
freely  separated  by  blunt  dissection. 


wall,  while  the  ultimate  results  are  equally  as  good  as  those  from  the  second  more 
radical  method.  Many  surgeons,  however,  prefer  the  flap-splitting  procedure. 
The  anterior  vaginal  wall  is  first  seized  with  tenacula  at  the  most  prominent 
part  of  the  cystocele.  The  tenacula  are  drawn  sharply  out,  leaving  a  ridge  of 
tissue  which  is  incised  for  a  short  distance  between  the  tenacula,  as  in  Fig.  255. 
With  the  aid  of  the  knife  and  with  blunt  dissection  the  incision  is  carried  into  the 
tissues  until  the  plane  of  cleavage  between  bladder  and  vagina  is  reached.     The 


618 


GYNECOLOGY 


two  surfaces  are  then  separated  by  blunt  dissection  so  as 
be  extended  in  both  directions.  Anteriorly  the  incision  is 
meatus  so  as  to  include  the  prominence  usually  described 
riorly  the  incision  is  carried  to  the  junction  of  cervix  and 
the  incision  are  seized  with  tenacula.  The  next  step  is  to 
as  possible  the  anterior  vaginal  wall  from  the  bladder. 


to  allow  the  incision  to 
carried  well  toward  the 
as  urethrocele.  Poste- 
bladder.  The  ends  of 
separate  as  completely 
This  is  done  mostly 


Fig.  257. — Anteeior  Colpoplastt  (Clark's 
Technic). 
Two  or  three  mattress  sutures  are  placed 
well  out  on  the  sides  and  in  relation  to  the  neck 
of  the  bladder.  In  the  drawing  they  are  repre- 
sented somewhat  nearer  the  meatus  than  they 
should  be.  These  sutures  are  placed  for  the 
purpose  of  relieving  functional  incontinence. 


W.p.Q, 


Fig.  258. — Anterior  Colpoplastt  (Clark's 
Technic). 
The  mattress  sutures  have  been  placed. 
The  hernial  protrusion  of  the  bladder  has  been 
infolded  by  a  buried  Gushing  stitch,  which  is 
passed  so  as  to  include  the  investing  fascia 
which  lies  between  the  vaginal  and  bladder 
walls. 


by  blunt  dissection  with  the  finger,  though  occasional  tissue  fibers  require  cutting 
with  scissors.  Gauze  should  not  be  employed  as  it  increases  the  danger  of  in- 
juring the  bladder.  All  bleeding  points  should  be  controlled  at  once  and  tied. 
The  separation  is  carried  out  well  down  on  the  sides  of  the  cystocele.  The 
urethra  in  its  upper  third  at  the  base  of  the  bladder  should  be  thoroughly  exposed. 
In  stripping  the  vagina  from  the  bladder  care  should  be  taken  to  leave  the  thin 


OPERATIONS    ON    THE    VAGINA 


619 


aponeurotic  membrane  which  will  be  found  investing  the  bladder.  This  will  be 
seen  to  be  slender  and  attenuated  at  the  center  of  the  cystocele,  but  strong  and 
well  marked  on  the  sides.  The  next  step  is  a  technical  maneuver  introduced  by 
J.  G.  Clark,  which  is  designed  to  control  the  functional  incontinence  from  which 
many  patients  with  cystocele  suffer  to  a  greater  or  less  extent.  Two  mattress 
sutures  of  No.  1  catgut  are  placed  well  up  into  the  angles  on  the  sides  of  the  urethra 


\vl 


MyOrr—- 


Fig.    259. — Anterior    Colpcplasty    (Clark's 
Technic). 
The  mattress  sutures  have  been  tied.     The 
excess   of   vaginal   mucous   membrane  is  being 
trimmed  away. 


\  / 

Fig.    260. — Anterior   Colpoplasty    (Clark's 

Technic). 

The  vaginal  wound  is  closed  with  interrupted 

catgut  sutures. 


and  crossing  the  urethra  near  its  junction  with  the  bladder  (Fig.  257).  The  ends 
of  the  sutures  are  clamped  and  not  tied  until  all  the  external  sutures  are  placed. 
The  next  step  in  the  operation  is  to  implicate  the  hernial  protrusion  of  the 
bladder  by  a  continuous  No.  1  catgut  suture.  Clark's  method  of  employing  the 
Cushing  stitch  is  an  excellent  one.  In  applying  the  implicating  stitch  it  should 
be  carried  well  out  on  the  sides  of  the  protruding  bladder  and  include  the  aponeu- 
rotic investiture  mentioned  above,  for  it  is  on  this  fascial  support  that  the  final 


620 


GYNECOLOGY 


success  of  the  operation  largety  depends.  When  the  imphcating  stitch  has  been 
apphed  it  will  be  found  that  there  usually  exists  a  greater  or  less  excess  of  vaginal 
membrane.  This  excess  of  membrane  is  then  trimmed  off.  The  amount  of 
membrane  to  be  removed  requires  good  judgment.  Care  must  be  taken  not 
to  cut  away  too  much,  for  if  the  edges  of  the  wound  are  approxunated  under  too 
great  tension  it  may  favor  the  later  formation  of  obstructmg  and  pauiful  scars  in 
the  vagina. 

The  wound  is  closed  with  interrupted  sutures  of  No.  1  chromic  gut. 

COMBINED    AMPUTATION    OF    CERVIX   AND    ANTERIOR    COLPOPLASTY 

The  f  oho  wing  operation  entails  a  more  extensive  anatomic  dissection  than 
does  the  Hegar's  amputation  combined  with  a  simple  anterior  colpoplasty,  and 


Fig.  261. — Amputation  of  Cervix  and  Anterior  Colpoplasty  (Studdiford). 

The  vaginal  mucous  membrane  over  the  cystocele  has  been  incised  and  the  vagina  and  bladder 

walls  freely  separated  bj^  blunt  dissection.     The  cervix  is  being  circumcised. 


should  not  be  attempted  by  an  inexperienced  operator.    The  technic  here  de- 
scribed is  in  general  that  recommended  by  W.  E.  Studdiford. 


OPERATIONS   ON    THE    VAGINA 


621 


The  cervix  is  grasped  with  double  hooks  and  drawn  strongly  outward  and 
downward  so  as  to  expose  the  entire  cystocele.  A  median  incision  is  made 
through  the  vaginal  mucous  membrane  from  a  point  |  or  f  inch  below 
the  meatus  to  the  junction  of  the  vagina  with  the  portio  vaginalis  of  the 
cervix.     The  plane  of  cleavage  is  found  between  the  vaginal  and  bladder  walls 


>/\<.^-(cXCvMtS 


Fig.  262. — Amputation  of  Cervix  and  Anterior  Colpoplasty  (Studdiford). 
The  bladder  has  been  exposed  and  stripped  back  from  the  cervix.     In  the  case  from  which  this 
drawing  was  made  the  cardinal  ligaments  were  exposed  on  the  right.     On  the  left  they  had  been  torn 
away  during  the  process  that  led  to  the  condition  of  prolapse. 

and  the  vagina  stripped  away  widely  on  each  side  of  the  central  incision.  It  is  of 
importance  to  carry  this  sphtting  of  the  two  walls  far  out  on  the  sides  of  the 
cystocele,  and  it  should  be  especially  thorough  at  the  level  of  the  neck  of  the  blad- 
der. The  cleavage  of  the  two  walls  is  accomplished  by  the  gloved  finger  and  with 
bknt  dissection.  Many  use  gauze  to  hasten  the  dissection,  but  this  technic  adds 
much  to  the  danger  of  rupturing  the  bladder  wall. 


622 


GYNECOLOGY 


When  the  dissection  of  the  surfaces  has  been  completed  the  cervix  is  cir- 
cumcised at  the  point  of  junction  of  the  vagina  and  portio.  The  vaginal  flaps 
are  seized  in  tenacula  and  drawn  outward  and  the  dissection  of  the  flaps  con- 
tinued behind  the  cervix.  This  gives  a  very  free  exposure  to  the  bladder,  which  is 
now  stripped  back  until  the  level  of  the  internal  os  is  reached.  The  extent  of 
this  part  of  the  dissection  depends  on  the  length  of  the  cervix,  which  in  marked 


Pig.  263. — Amputation  of  Cervix  and  Axterior  Colpoplasty  (Studdiford). 
The  hernial  protrusion  of  the  bladder  has  been  infolded  by  a  Gushing  stitch. 


cases  of  procidentia  is  usually  considerable.  The  cervix  is  still  further  freed 
laterally  and  posteriorly.  As  the  elongated  cervix  is  developed  the  fibers  of  the 
important  cardinal  ligaments  are  brought  into  view,  unless  they  have  been  torn 
or  stretched  away  during  the  process  of  the  uterine  prolapse. 

When  the  cervix  has  been  fully  developed  attention  is  directed  to  the  bladder. 
A  Gushing  stitch  is  applied  well  out  on  the  sides  of  the  cystocele  so  as  to  infold 
the  central  part  of  the  protruding  cystocele.     Care  should  be  taken  that  the 


OPERATIONS    ON    THE    VAGINA 


623 


suture. includes  at  each  bite  a  firm  hold  of  the  fascia  which  invests  the  bladder. 
In  passing  the  stitch  at  the  level  of  the  neck  of  the  bladder  the  needle  is  carried 
deeply  into  the  firm  tissue  which  Hes  at  the  sides  of  the  urethra.  This  serves  to 
rectify  the  functional  incontinence  with  which  many  of  these  patients  are 
troubled.  It  is  a  good  plan  at  this  stage  to  introduce  the  retention  mattress 
stitch  depicted  on  page  618.  When  the  protruding  cystocele  has  been  implicated 
the  amputation  of  the  cervix  follows  as  the  next  step. 


V/.PGr^ 


Fi6.  264. — Amputation  of  the  Cervix  and  Anterior  Colpoplasty  (Studdiford). 
The  cervix  has  been  bisected  and  the  two  lips  are  to  be  amputated  by  wedge-shaped  incisions. 


The  cervix  is  first  bisected  by  a  lateral  incision  up  to  the  point  selected  for 
the  amputation.  The  lips  are  drawn  apart  as  in  Fig.  264.  Each  lip  is  separately 
amputated  by  a  wedge-shaped  incision  as  depicted  in  the  drawing,  so  as  to  leave 
two  pouting  projections  on  each  Hp  (Fig.  264).  The  object  of  this  is  to  secure 
an  everting  tube-shaped  opening  for  the  uterine  canal. 

Two  catgut  sutures  are  placed  first  through  the  posterior  cervical  lip-stump 


624 


GYNECOLOGY 


and  into  the  vaginal  wall  of  corresponding  points  (Fig.  265)  and  tied.  Two 
sutures  are  then  placed  through  the  anterior  stump  and  including  the  angles  of 
the  vaginal  flaps  at  each  side  of  the  original  longitudinal  incision.  Sutures  are 
placed  at  the  angles  of  the  cervical  stump  and  into  the  edges  of  the  mucous  mem- 
brane on  each  side  (Fig.  266).     The  final  step  is  to  complete  the  cystocele  opera- 


fduc  memb 


Fig.   265. — Amputation   of   Ceevix  and  An- 
terior COLPOPLASTY  (StUDDIFORd). 

The  cervix  has  been  amputated.  The 
mucous  membrane  of  the  endocervix  is  being 
united  to  the  vaginal  mucous  membrane.  Note 
the  manner  in  which  the  lips  of  the  cervical 
stump  are  included  in  the  sutures. 


\\l,P.&r-N 


Fig.   266. — ^Amputation    of    Cervix  and  An- 
terior Colpoplasty  (Studdiford). 

The  stitches  in  the  cervical  stump  have 
been  tied.  The  edges  of  the  vaginal  mucous 
membrane  are  being  coaptated  by  a  subcutic- 
ular stitch. 


tion  by  uniting  the  two  flaps  of  vaginal  wall.  In  most  cases  the  tissue  is  redun- 
dant and  should  be  judiciously  trimmed  off.  The  edges  may  be  united  by  a 
subcuticular  running  Gushing  stitch  or  by  interrupted  sutures,  preferably  the 
latter. 


OPERATIONS    ON    THE    VAGINA 


625 


EMMET'S  PERINEOPLASTY.     (AUTHOR'S    TECHNIC.) 

First  Step. — The  posterior  wall  of  the  vagina  is  grasped  with  a  pair  of  Cullen 
hooks  at  a  point  which  when  approximated  to  the  anterior  vaginal  wall  wiU 
touch  it  at  the  junction  of  the  anterior  and  middle  thirds  of  the  urethra.  If  a 
cystocele  has  been  performed  by  the  method  described  on  page  608  the  point  will 
correspond  to  the  crown  stitch  on  the  anterior  wall.  A  tenaculum  is  then  placed 
just  inside  the  opening  of  the  left  Bartholin's  gland  and  drawn  sharply  outward, 


\\t.^t^- 


|%C\V>C*^ 


Fig.  267. — Operation  for  Laceration-  of  the  Perineum.  (Emmet's  method.) 
Exposure  of  the  lateral  sulci  and  external  perineum.  Tenacula  are  placed  at  the  orifices  of  the 
ducts  to  Bartholin's  glands  and  drawn  outward.  A  tenaculum  or  bullet  forceps  seizes  a  point  on  the 
posterior  vaginal  wall  which  when  approximated  to  the  anterior  vaginal  wall  will  touch  it  at  the 
point  of  junction  of  the  middle  and  outer  thirds  of  the  urethra.  In  denuding  the  lateral  sulcus  a 
tenaculum  is  placed  at  the  natural  angle  formed  by  exposing  the  sulcus.      (See  Fig.  268.) 

while  the  traction  forceps  attached  to- the  posterior  wall  is  drawn  in  the  opposite 
direction.  This  exposes  a  triangular  depressed  area  or  sulcus  with  the  apex  inside 
the  vagina.  The  size  of  this  area  represents  the  amount  of  separation  of  the 
anterior  fibers  of  the  levator  ani  muscles  (puborectalis)  from  the  sides  of  the 
rectum.  In  the  normal  perineum,  or  one  in  which  there  has  been  no  separation 
of  the  puborectalis,  the  triangular  sulcus  is  either  absent  or  insignificant. 

A  tenaculum  is  placed  in  the  apex  of  the  triangle.     The  instruments  attached 
to  the  three  angles  are  drawn  strongly  in  divergent  directions,  so  that  the 

40 


626 


GYNECOLOGY 


triangle  is  mapped  out  by  the  tense  folds  of  mucous  membrane  between  them. 
Denudation  of  the  triangle  is  best  performed  with  Emmet's  scissors,  which 
first  cut  smoothly  along  the  tense  lines  of  mucous  membrane  and  then  remove 
the  intervening  tissue.  The  denudation  can  be  done  very  rapidlj^  by  this  method. 
The  tenaculum  forceps  on  the  posterior  w^all  are  then  drawn  in  the  opposite  direc- 
tion and  a  tenaculum  placed  at  the  opening  of  the  right  Bartholin's  gland.  The 
instruments  are  drawn  apart  and  the  triangular  sulcus  of  the  right  side  exposed. 
The  two  triangles  are  rarely  alike,  as  the  separation  of  the  puborectalis  muscle 
is  nearly  always  greater  on  one  side  than  on  the  other.    "When  this  area  is  denuded 


"T^ec<;oce\(L-' 


Fig.  268. — Operation  for  Laceratiox  of  the  Perijjeum.      (Emmet's  method.) 
The  left  lateral  sulcus  has  been  exposed  and  denuded. 

in  the  same  mariner  as  that  of  the  other  side,  the  traction  forceps  is  drawn 
upward  toward  the  pubes  in  the  middle  line,  while  the  tenacula  in  Bartholin's 
ducts  continue  to  exert  traction  outward  in  opposite  directions  (Fig.  269).  By 
this  maneuver  a  third  triangle  is  exposed  corresponding  to  the  so-called  external 
perineum.  This  area  is  denuded,  the  first  strip  of  membrane  being  removed  b}^ 
cutting  smoothly  from  one  tenaculum  to  the  other.  All  important  bleeding 
points  of  the  exposed  surface  should  be  tied  with  fine  catgut. 

Beginning  now  on  the  patient's  left  the  inside  stitches  are  placed  with  the 
purpose  of  closing  up  the  sulcus  caused  by  the  rupture  of  the  puborectalis 
muscles,  and  restoring  the  former  lateral  vaginal  support  of  the  rectum.     The 


OPERATIONS    ON    THE    VAGINA 


627 


proper  placing  of  these  sutures  is  of  supreme  importance  when  there  is  any 
considerable  amount  of  rectocele  present.  The  triangular  denuded  area  is 
now  exposed  by  traction  on  the  forceps  and  tenaculum.  A  catgut  suture  is 
then  introduced,  beginning  at  the  outer  side  of  the  apex  of  the  triangle.  It  is 
carried  directly  toward  the  operator,  dipping  well  into  the  levator  ani  muscle, 
and  is  brought  out  in  the  external  perineum.     It  is  then  reintroduced  in  the  side 


Fig.  269. — Operation  for  Lacerated  Perineum.     (Emmet's  method.) 
The  two  lateral  triangles  have  been  denuded  and  the  third  triangle  of  the  external  perineum  is 
being  exposed  for  denudation.     The  first  cut  with  the  scissors  is  in  an  even  curving  direction  from 
tenaculum  to  tenaculum — the  intervening  tissue  is  then  removed. 


of  the  rectal  portion,  quilted  superficially  in  the  tissue,  and  carried  directly 
backward  toward  the  apex,  where  it  emerges  in  the  mucous  membrane  opposite 
the  point  from  which  it  started.  It  is  thus  seen  that  the  suture  takes  a  V-shaped 
course,  with  the  apex  of  the  V  in  the  external  perineum,  one  leg  of  the  V  in  the 
levator  ani  muscle,  and  the  other  in  the  side  of  the  rectum  (Fig.  270).  It 
therefore  reproduces  quite  faithfully,  when  tied,  the  attachment  of  the  pubo- 
rectalis  muscle.     Two  or  three  more  stitches  are  then  introduced  in  like  manner. 


628 


GYNECOLOGY 


If  there  is  a  rectocele  present,  the  suture,  which  is  quilted  into  the  rectal  portion, 
is  curved  around  more  and  more  toward  the  front,  so  that  the  last  suture  reaches 
the  middle  hne  (Fig.  271).  The  suture  ends  are  clamped  and  the  triangular 
sulcus  of  the  other  side  is  treated  in  the  same  manner.  When  all  the  sutures 
have  been  tied  it  will  be  found  that  the  rectocele  has  entirely  disappeared. 
By  employing  this  method  it  is  possible  completely  to  reduce  a  rectocele  of  any 
size,  with  only  a  rare  recurrence,  and  it  is  this  part  of  the  Emmet  operation 


Fig.  270. — Operation  for  Laceration  of  the  Perineum.     (Emmet's  method.) 
The  denudation  is  complete.     Sutures  have  been  introduced  in  the  left  lateral  sulcus.     They  are 
brought  outward  toward  the  external  perineum,  and  then  inward,  making  a  V  shape  with  the  apex 
in  the  external  perineal  region. 


which  makes  it  superior  to  others  for  the  treatment  of  rectocele  and  extensive 
relaxation  of  the  perineum. 

Second  Step. — Having  disposed  of  the  rectocele,  and  restored  the  lateral 
vaginal  attachments  of  the  rectum,  attention  is  now  directed  to  bringing  together 
the  separated  levator  ani  and  transversus  perinei  muscles.  In  order  to  expose 
the  field  of  operation  and  to  indicate  the  final  position  of  the  perineal  body,  the 
last  two  internal  sutures  are  not  cut,  but  clamped  together,  and  drawn  strongly 
upward  by  the  assistant  until  the  posterior  wall  of  the  introitus  touches  the 
anterior,  and  held  in  this  position  until  the  end  of  the  operation  (Fig.  273). 


OPERATIONS    ON    THE    VAGINA 


629 


The  tissue  of  the  external  perineum  is  now  dissected  so  as  to  give  access  to 
the  separated  levator  ani  muscles.  This  is  quite  important,  especially  when 
there  is  a  considerable  amount  of  scar-tissue  present.  No  attempt  is  made  to 
develop  the  muscular  fibers  of  the  levator  muscles,  for  in  this  way  fascial  tissue 
is  removed  which  is  valuable  for  the  purpose  of  union  in  healing.  The  fascial 
covering  of  the  muscles  should,  however,  be  cleared  of  intervening  scar  and 


Fig.  271. — Opj:ration  for  Rectocele. 
The  denudation  is  carried  out  as  in  the  usual  Emmet's  perineoplasty.  The  reduction  of  the 
rectocele  is  accomplished  entirely  during  the  suturing  of  the  lateral  sulci.  The  stitches  are  carried 
deeply  into  the  levator  muscles  on  the  sides.  They  are  quilted  into  the  rectal  portion  in  the  manner 
here  shown,  each  one  being  carried  further  around  toward  the  front  until  the  last  (fourth)  stitch 
reaches  the  median  line  of  the  rectocele.  When  the  stitches  on  both  sides  are  drawn  taut  the  rec- 
tocele is  made  to  disappear. 

fatty  tissue.  In  order  to  facilitate  the  isolation  and  clearing  of  the  muscles 
long-pointed  tenacula  are  carried  deep  into  the  lower  portion  of  the  levators  to 
the  sides  of  .the  sphincter  ani,'  and  the  muscle  bellies  brought  prominently  into 
view  in  the  manner  depicted  in  Figs.  273,  274.  After  removing  all  intervening 
tissue  that  may  interfere  with  the  union  of  the  muscles,  a  figure-of-8  catgut  stitch 
is  introduced  so  as  to  create  a  broad  surface  of  approximation  of  the  two  muscte 


630 


GYNECOLOGY 


Fig.  272. — Operation  fob  Rectocele. 

Running  buried  catgut  stitch  implicating  the 
rectal  wall.  This  stitch  is  useful  when  there  is 
marked  hernial  protrusion  of  the  rectum.  When 
the  stitch  has  been  placed  the  lateral  sulci  are 
closed  in  the  usual  way. 


Fig.  273. — Operation  for  Lacerated  Peri- 
neum. 
The  stitches  of  the  internal  part  have  been 
tied  and  cut  with  the  exception  of  the  last  two 
sutures,  the  ends  of  which  are  left  long  to  serve 
as  tractors.  The  wound  edge  of  the  external 
perineum  is  trimmed  so  that  the  denuded  fig- 
ure is  exactly  symmetric.  The  drawing  shows 
the  levator  muscles  being  freed,  so  that  they 
can  be  easily  approximated  without  tension. 


OPERATIONS    ON    THE    VAGINA 


631 


bellies  (Fig.  274).  This  suture  is  ultimately  to  be  buried.  It  is  drawn  taut  and 
clamped.  The  sutures  of  the  external  perineum  are  next  applied,  beginning 
at  the  top.     The  first  stitch  is  merely  for  superficial  approximation.     It  passes 


Vi.v 


Lacerated  Peri- 


Fig.  275. — Operation  for 

NUEM. 

The  deep  figure-of-8  catgut  stitch  has  been 
tied  and  cut,  thus  approximating  the  levator  ani 
muscles.  Deep  silkworm-gut  sutures  have  been 
placed  and  are  ready  to  be  tied  and  shotted. 


Fig.  274. — Operation  for  Lacerated  Perineum. 
The  internal  part  of  the  operation  has  been 
finished  and  the  last  two  stitches  left  long,  so 
that  they  may  be  used  as  retractors.  The  skin 
has  been  freed  up  from  the  levator  muscles.  A 
buried  figure-of-8  approximation  stitch  of  chromic- 
ized  catgut  No.  0  has  been  introduced.  The  ends 
are  not  tied  until  the  external  stitches  have  been 
placed. 

from  side  to  side,  including  the  small  tongue  of  vaginal  mucous  membrane  be- 
tween the  two  last  internal  sutures.  This  tongue  should  first  be  trimmed  so 
that  when  the  suture  is  tied  there  will  be  perfect  coaptation  of  the  wound 
edges.      Other   sutures   are   now   introduced,   each   one   dipping   deeply   into 


632 


GYNECOLOGY 


the  bellies  of  the  levator  ani  muscle,  thus  reinforcing  the  buried  figure-of-8 
stitch.  The  upward  tension  on  the  two  internal  stitches  that  are  being  held 
by  the  assistant  should  not  be  released  until  every  suture  is  tied.  The  tying 
of  the  external  sutures  is,  therefore,  best  begun  at  the  anal  end  of  the  external 


Fig.  276. — Operation  for  Lacer.\ted  Perineum. 
In  this  operation  a  central  denudation  has  been  made  and  the  sutures  introduced  from  side  to 
side,  including  the  levator  ani  muscles  from  the  point  where  they  can  be  approximated.     The  inside 
sutures  are  of  catgut  and  outside  sutures  of  silkworm-gut.    This  operation  is  not  as  serviceable  as  the 
Emmet  operation  when  there  is  much  relaxation  of  the  outlet.      (Adapted  from  Holden's  operation.) 

wound.     When  all  the  stitches  have  been  tied,  the  posterior  surface  of  the  in- 
troitus  should  impinge  on  the  anterior. 


Most  operators  at  the  present  day  use  catgut  for  the  external  perineal  stitches  instead  of 
silkworm-gut.  Extensive  experience  with  both  sutures  has  convinced  us  that  silkworm-gut 
sutures,  individually  shotted,  conduce  in  the  long  run  to  cleaner  wounds,  shorter  convalescences, 
and  better  end-results.  The  necessity  of  removing  them  on  the  ninth  day  is  a  disadvantage 
which  is  more  than  counterbalanced  by  the  superiority  of  the  local  results. 


OPERATIONS    ON    THE    VAGINA 


633 


CLARK'S   PERINEOPLASTY^ 

As  has  been  previously  stated,  the  distinctive  principle  of  the  Emmet  opera- 
tion consists  in  reducing  the  rectocele  by  drawing  up  the  rectum  on  each  side  in 
the  direction  of  the  attachments  of  the  levator  ani  muscles  to  the  pubic  rami. 
In  another  type  of  operation  the  rectal  hernia  is  reduced  by  drawing  the  tissues 
together  in  the  middle  line.  The  cardinal  principle  of  this  method  depends  for 
its  success  on  employing  the  support  of  the  aponeurotic  pelvic  fascia  which  in- 
vests the  rectocele  in  the  plane  between  the  vaginal  and  rectal  walls.  Hence  this 
method  resembles  in  principle  the  various  operations  for  hernias  involving  the 
abdominal  wall.     There  are  numerous  modifications  of  the  central  type  of  perine- 

/A 


Fig.  277. — Clark's  Pertneopi^sty. 

Outline  of  area  of  denudation.     The  line  from  the  lateral  tenacula  to  the  central  tenaculum  is  not 

straight,  but  forms  an  angle  into  the  sulcus  on  each  side. 

oplasty.  Of  these,  we  have  found  the  technic  used  by  Dr.  J.  G.  Clark  especially 
practical. 

The  Operation. — The  field  of  operation  is  exposed  by  grasping  the  sides  of 
the  introitus  at  the  Bartholin  openings  with  Teale's  tenacula.  A  tenaculum  is 
then  inserted  in  the  posterior  wall  of  the  vagina  at  a  central  point  two -thirds  the 
distance  from  the  introitus  to  the  cervix.  When  traction  is  made  on  the  three 
tenacula  thus  placed  the  field  of  operation  is  thoroughly  exposed  and  the  outline 
of  the  area  to  be  denuded  is  marked  out  with  a  scalpel  as  in  Fig.  277. 

A  distinctive  and  important  feature  of  the  denudation  is  the  creation  of  the 
two  angular  flaps  of  vaginal  tissue  which  may  be  seen  in  the  illustration  to  have 

1  The  drawings  illustrating  Dr.  Clark's  method  of  performing  anterior  colpoplasty  and  peri- 
neoplasty do  not  strictly  accord  in  a  few  minor  details  with  Dr.  Clark's  technic.  Owing  to  the 
haste  in  pubUcation  there  was  no  opportunity  to  make  the  necessary  changes  in  the  drawings. 


634 


GYNECOLOGY 


their  apices  in  the  lateral  sulci  at  the  sides  of  the  rectocele.  By  leaving  these 
angular  flaps  the  vaginal  mucous  membrane  may  be  coaptated  in  the  median  line 
without  undue  tension,  and  hence  with  httle  danger  of  causing  the  formation  of 
obstructing  vaginal  bands. 

When  the  area  thus  outhned  has  been  thoroughly  and  deeply  denuded  the  two 
angular  flaps  are  dissected  free  as  in  Fig.  278  in  order  to  give  greater  opportunity 
for  carrying  out  the  next  step  of  turning  in  the  hernial  protrusion  of  the  rectocele. 

In  imphcating  the  rectocele  a  running  Gushing  stitch  of  No.  0  chromicized 
catgut  is  carried  from  the  upper  angle  of  the  denuded  area  and  continued  outward 


Fig.  278. — Clark's  Perineopl.isty. 
Denudation  of  the  area  and  freeing;  of  the  anuglar  flaps. 


toward  the  operator  sufficiently  far  to  include  the  whole  of  the  hernial  protrusion. 
In  placing  the  Gushing  stitch  it  is  of  great  importance  to  include  the  aponeurotic 
fascia  which  is  found  to  be  of  definite  strength  and  thickness  on  the  sides  of  the 
protruding  mass.  When  this  buried  running  stitch  has  been  placed  and  tied  the 
mucous  membrane  of  the  vagina  is  coaptated  by  interrupted  sutures  of  No.  1 
chromicized  catgut  beginning  at  the  upper  central  angle  of  the  denuded  area. 
These  stitches  are  placed  as  firmly  in  the  tissues  as  possible  so  as  to  reinforce  the 
buried  stitch,  but  not  deeply  enough  to  injure  the  rectal  wafl.  When  the  apices 
of  the  angular  flaps- are  reached  the  remaining  stitches  are  placed  very  deeply 


OPERATIONS    ON    THE    VAGINA 


635 


and  well  out  on  the  sides  in  order  to  include  the  separated  bellies  of  the  levator 
ani  muscles.  The  interrupted  sutures  are  consecutively  introduced  until  the 
points  of  entrance  of  the  Bartholin  glands  are  reached.  All  the  interrupted 
stitches  are  then  tied.  The  last  step  of  the  operation  consists  in  uniting  the 
muscles  of  the  external  perineum  by  a  return  buried  catgut  stitch  of  No.  0  catgut 
placed  in  the  following  manner: 

A  tenaculum  seizes  the  edge  of  the  external  wound  at  a  point  equidistant  from 
the  two  lateral  retraction  tenacula.  By  drawing  the  middle  tenaculum  sharply 
downward  the  denuded  surface  of  the  external  perineal  wound  is  exposed  in  the 


^"^. 


{ 


Fig.  279. — Clark's  Perineoplasty. 
The  area  has  been  denuded  and  the  angu- 
lar flaps  in  the  sulci  freed.  The  central  part  of 
the  rectal  hernia  is  being  infolded  by  a  buried 
Gushing  stitch.  This  stitch  is  passed  into  the 
fascial  tissue  which  invests  the  rectal  wall  be- 
tween vagina  and  rectum. 


Fig.  280. — Clark's  Perineoplasty. 
Insertion  of  central  stitches.     The  last  four 
stitches  are  placed  deeply  in  the  bellies  of  the 
levator  (pubococcygeus)  muscles. 


form  of  a  triangle  with  the  apex  toward  the  sphincter.  A  catgut  suture  is  intro- 
duced near  the  duct  of  the  left  Bartholin  gland  and  carried  deeply  into  the 
tissues,  including  the  muscular  masses  of  the  levator  ani  and  transversus  perinei 
muscles.  It  is  passed  from  side  to  side  in  the  same' manner  as  a  Gushing  stitch 
and  continued  to  the  lower  angle  of  the  exposed  area.  Having  reached  this  point 
it  is  then  returned  in  the  reverse,  direction,  more  superficially  but  still  placed 


636 


GYNECOLOGY 


sufficiently  deep  to  secure  not  only  an  exact  coaptation  of  the  skin  edges,  but 
also  a  firm  union  of  the  subcutaneous  tissues.  Having  reached  on  its  return 
journey  the  level  of  the  introitus,  the  stitch  is  carried  outward  through  the 
vaginal  mucous  membrane  near  the  duct  of  the  right  Bartholin  gland.  When 
the  two  free  ends  (Fig.  282)  are  snugly  tied  the  external  perineum  will  be  found 
to  be  neatly  closed  without  the  exposure  of  a  knot. 


Fig.  281. — Clark's  Perineoplasty. 
The  central  stitches  have  been  tied  and  cut. 
A  buried  Gushing  stitch  has  been  started  at  the 
upper  end  of  the  external  wound  and  carried 
deeply  on  each  side  to  the  lower  end  of  the 
wound.  It  is  now  continued  as  a  subcuticular 
stitch  to  the  point  whence  it  started. 


Fig.  282. — Clark's  Perineoplasty. 
The  subcuticular   stitch  is   just  being   fin- 
ished.    When  tied  the  external  wound  is  com- 
pletely closed  without  exposure  of  the  knot. 


Operation  for  Complete  Tear. — When  the  perineal  tear  involves  the  sphincter 
ani  muscle  the  first  part  of  the  operation  is  carried  out  in  every  way  as  above 
up  to  the  point  where  the  buried  stitch  of  the  external  perineum  reaches  the  limit 
of  its  outward  journey.  At  this  point  the  stitch  is  tied  and  cut.  The  denudation 
of  the  skin  of  the  external  perineum  is  then  extended  as  in  Fig.  283  so  as  to  expose 
the  ends  of  the  torn  sphincter.  A  new  buried  catgut  suture  is  next  placed  at  the 
point  where  the  first  was  tied,  and  cut  and  continued  downward,  being  placed 
deeply  on  each  side  close  to  but  not  including  the  rectal  mucous  membrane. 


OPERATIONS    ON    THE    VAGINA 


637 


By  drawing  the  stitch  tight  when  it  reaches  the  external  skin  of  the  anus  the 
ruptured  mucous  membrane  of  the  rectum  will  be  approximated  without  exposure 
of  the  stitch.  The  buried  stitch  is  now  clamped  while  the  next  step  is  carried  out. 
This  consists  in  securing  with  tenacula  the  ends  of  the  torn  sphincter  and  draw- 
ing them  prominently  out  to  view.     The  sphincter  ends  should  be  dissected  clean 


Fig.  283. — Clark's  Perineoplasty  for  Com- 
plete Tear. 
The  first  part  of  the  operation  is  performed 
as  for  a  simple  tear.  The  area  for  exposing  the 
ruptured  ends  of  the  sphincter  is  outHned  and 
denuded.  In  the  above  drawing  the  buried  cat- 
gut Gushing  suture  approximating  the  levator 
muscles  is  represented  as  having  been  already 
introduced.  It  is  better  not  to  introduce  this 
suture  until  the  ends  of  the  sphincter  have  been 
secured,  as  in  Fig.  284. 


W.P^Gr ■ 

Fig.  284. — Clark's  Perineoplasty  for  Com- 
plete Tear. 
The  ends  of  the  sphincter  have  been  secured 
by  tenacula.  The  buried  Cushing  stitch  has 
been  applied.  It  is  best  to  tie  the  buried  suture 
at  this  point  and  to  continue  later  with  a  new 
stitch  as  will  be  seen  in  Fig.  285. 


of  scar  tissue  so  that  they  may  be  approximated  freely  and  without  tension. 
Three  interrupted  catgut  sutures  No.  0  are  placed  so  as  to  unite  the  ends  fii-mly 
together  (Fig.  285).  The  buried  catgut  suture  is  then  continued  as  in  the 
operation  for  simple  tear,  and  when  tied  with  the  free  end  at  the  introitus 
(Fig.  286)  completes  the  operation. 


638 


GYNECOLOGY 


Fig.  285. — Ci^^rk's  Pkrineoplasty  for  Com- 
plete Tear. 
The  first  buried  stitch  has  been  placed  and 
tied.  A  second  buried  stitch  is  then  introduced 
and  continued  so  as  to  approximate  the  torn 
edges  of  the  rectal  wall.  The  end  of  this  stitch 
is  seen  in  the  drawdng  extruding  beneath  the 
sphincter  muscle  and  is  to  be  used  as  a  .sub- 
cuticular stitch  to  close  the  wound.  After  the 
buried  suture  has  been  placed  the  ends  of  the 
sphincter  are  brought  together  and  united  by 
three  interrupted  catgut,  sutures  as  shown  in  the 
drawing. 


Fig.  2S6. — Clark's  Perineoplasty  for  com- 
plete Tear. 
The  buried  suture  seen  mth  its  end  free  in 
the  lower  part  of  the  pre^^ous  drawing  has  been 
continued  as  a  subcuticular  stitch  and  is  about 
to  be  tied  to  the  free  end  of  the  first  buried 
.suture.  When  these  ends  are  tied  the  wound  of 
the  external  perineum  is  closed  without  the  ex- 
posure of  a. knot. 


STUDDIFORD'S   PERINEOPLASTY  ^ 

The  operation  elaborated  by  Studdif ord  fox  the  repair  of  the  lacerated  peri- 
neum is  studiously  based  on  the  exact  anatomy  of  the  parts. 

Before  attempting  to  follow  the  steps  of  the  operation  the  reader  should  refer 
to  Studdiford's  description  of  the  anatomy  and  function  of  the  perineum  quoted 
in  detail  in  Part  II  of  this  book. 

Tenacula  are  applied  at  the  caruncles  which  mark  the  openings  of  BarthoHn's 
glands.  Strong  outward  traction  on  the  tenacula  brings  into  prominence  the 
mucocutaneous  border  of  the  posterior  vaginal  wall.  A  Kocher  forceps  or  tenac- 
ulum is  then  inserted  at  the  apex  of  the  tab  of  mucous  membrane  which  is  always 
outlined  between  the  two  lateral  sulci  of  the  vagina.  This  point  is  often  marked 
by  an  isolated  caruncle.     The  mucocutaneous  border  is  incised  from  tenaculum 

1  The  illustrations  of  this  operation  were  made  from  sketches  drawn  while  watching  Dr.  Stud- 
dif ord 'operate.  Owing  to  the  necessity  of  haste  in  pubUcation  there  was  no  opportunity  to  submit 
the  finished  drawings  to  Dr.  Studdiford  for  inspection. 


OPERATIONS    ON    THE    VAGINA 


639 


to  tenaculum  and  the  tissues  freed  by  blunt  dissection  with  scissors.  Scar  tissue 
will  be  found  on  each  side  corresponding  to  the  two  lateral  sulci.  These  scars  are 
fhst  nicked  with  scissors  and  an  opportunity  given  to  insert  the  finger  into  each 
sulcus  beneath  the  vaginal  mucous  membrane.  With  the  forefinger  in  the  sulcus 
the  scar  may  be  readily  brought  into  view  by  upward  pressure- on  the  vaginal 
mucous  membrane  (Fig.  287).  The  scar  tissue  of  each  sulcus  is  excised  in  the 
manner  shown  in  Fig.  288.     The  denuded  area  is  now  similar  in  outline  to  that 


Fig.  287. — Sttjddiford's  Perineoplasty. 
Initial  incision.     Tenacula  have  been  applied  at  the  caruncles  and  drawn  outward.     The  mucocuta- 
neous border  has  been  incised.     The  tissues  are  being  separated  by  blunt  dissection  with  scissors. 


of  the  Emmet  operation  except  that  the  two  wings  of  the  area  are  asymmetric 
on  account  of  the  difference  that  usually  exists  in  the  extent  of  the  two  lateral 
scars. 

The  perineal  muscles  and  trigone  are  next  developed,  obstructing  scar  tissue 
being  dissected  away.  The  muscles  are  not  bared  to  their  muscle-fibers,  but  are 
brought  to  view  in  their  fascial  investments.     The  deep  sutures  are  now  placed. 

A  suture  with  needle  at  each  end  is  started  at  the  rectal  protrusion  surmounted 
by  the  central  vaginal  tab.     The  needle  is  then  passed  very  deeply  into  the  pubo- 


640 


GYNECOLOGY 


coccygeus  muscle  of  the  one  side  behind  and  not  including  the  trigone.  The  needle 
of  the  other  end  of  the  suture  is  then  carried  into  the  belly  of  the  other  pubo- 
coccygeus  muscle.     The  final  course  of  the  suture  is  to  include  the  anterior  end 


Vv^.v^  Gjx-c^^it-?, 


Fig.  288. — Studdifoed's  Perineoplasty. 
Exposure  of  the  lateral  sulci.     The  vaginal  mucous  membrane  is  freed  in  the  two  sulci  by  for- 
cibly inserting  the  forefinger  beneath  the  scars.     The  scar  tissue  is  cut  away  as  in  the  drawing.     The 
mucous  membrane  of  the  left  sulcus  has  been  removed.     That  on  -the  right  is  about  to  be  incised. 
The  final  appearance  is  similar  to  that  of  the  denudation  of  Emmet's  perineoplasty. 

of  the  sphincter  muscle,  that  end  of  the  suture  being  applied  which  will  best  draw 
the  sphincter  toward  the  side  on  which  the  laceration  was  deeper.  A  second  deep 
suture  is  applied  in  the  same  manner. 

The  next  step  is  to  close  the  lateral  sulci  which  have  been  thus  exposed. 


OPERATIONS    ON   THE    VAGINA 


641 


This  is  done  with  a  running  subcuticular  Gushing  stitch  starting  from  the  apex 
and  extending  to  the  base  of  each  lateral  triangle,  care  being  taken  to  secure  as 
far  as  possible  the  investing  fascia.  (In  the  drawings  this  step  precedes  the 
placing  of  the  deep  stitches.)  When  the  subcuticular  sutures  have  been  tied  the 
stitch  of  the  left  side  is  passed  through  the  upper  end  of  the  right  trigone  and 
the  stitch  of  the  right  side  is  passed  through  the  upper  end  of  the  left  trigone 


Fig.  289. — -Studdifoed's  Perineoplasty. 
Approximation  of  the  pubococcygeus  muscles.  The  two  lateral  sulci  have  been  closed  by  buried 
Gushing  sutures,  the  ends  of  which  are  left  long.  The  bellies  of  the  levator  ani  muscles  are  being 
united  by  two  buried  sutures.  One  suture  has  already  been  placed  and  tied.  The  second  suture 
is  being  placed.  The  suture  is  equipped  with  a  needle  at  each  end.  A  bit  of  tissue  is  first  included 
in  the  median  line  under  the  central  tongue  of  mucous  membrane.  It  is  passed  on  each  side  deeply 
into  the  levator  pubococcygeus  muscles  behind  the  trigone.  The  upper  fibers  of  the  sphincter  ani 
muscle  are  included  in  the  suture. 


(Fig.  290).  The  two  sutures  are  tied  and  kept  long.  This  unites  what  may  be 
termed  the  crown  of  the  perineum.  The  two  ends  of  the  united  suture  are  then 
used  to  close  the  external  wound.  One  end  unites  the  edges  of  the  trigone,  and 
is  returned  as  a  subcuticular  stitch  to  approximate  the  skin  edges.  The  two 
ends  are  then  tied  in  such  a  way  as  to  bury  the  knot. 

If  there  is  marked  rectocele  present  special  measures  must  be  taken.     In 

41 


642 


GYNECOLOGY 


case  of  high  rectocele  Studdiford  advocates  a  central  incision  through  the  mucous 
membrane  of  the  posterior  vaginal  wall.  The  vagina  and  rectum  are  separated 
widely  on  each  side  of  the  central  incision.  When  the  rectum  has  been  well 
mobilized  the  hernial  protrusion  is  implicated  by  a  running  stitch,  as  in  Clark's 
operation.  The  excess  of  vaginal  mucous  membrane  is  trimmed,  if  necessary, 
and  coaptated,  preferably  by  interrupted  catgut  sutures.  The  rest  of  the 
operation  is  then  carried  out  as  described  above.  Studdiford,  like  Clark  and 
others,  recommends  in  addition  to  the  plastic  operation  for  rectocele  the  prin- 


FiG.  290. — Studdifokd's  Perineoplasty, 
Approximation  of  the  trigone.  The  pubococcygeus  muscles  have  been  united  by  two  buried 
sutures  which  have  been  tied  and  cut.  The  long  ends  of  the  Gushing  sutures  wliich  have  closed  the 
lateral  sulci  are  now  employed  to  unite  the  trigone.  Each  suture  is  crossed  over  and  inserted  in  the 
upper  end  of  the  trigone.  The  ends  are  then  firmly  tied,  thus  bringing  the  upper  ends  of  the  trigone 
together  and  in  relation  to  the  central  tongue  of  mucous  membrane. 


ciple  of  closing  the  posterior  culdesac  through  an  abdominal  incision.  This 
may  be  accomplished  either  by  the  Moschowitz  technic  for  rectal  prolapse  or  by 
the  author's  modification  described  on  page  644. 

If  the  rectocele  is  low,  the  levator  ani  muscles  (pubococcygei)  are  brought 
together  in  the  median  line  as  high  up  as  possible,  so  as  to  interpose  them  between 
the  rectum  and  vagina.  This  is  the  principle  employed  in  the  so-called  central 
operations  of  which  Holden's  operation  {q.  v.)  is  a  type. 


OPEKATIONS    ON    THE    VAGINA 


643 


A 


Vno^oae 


Fig.  291. — Studdiford's  Perineoplasty. 
Closure  of  the  external  perineum.  The  sutures  which  were  inserted  in  the  upper  ends  of  the 
trigone  have  been  tied  and  the  ends  still  left  long.  One  suture  is  then  continued  downward  so  as  to 
approximate  the  sides  of  the  trigone.  After  reaching  the  lower  limit  of  the  wound  it  is  then  returned 
as  a  subcuticular  stitch  to  the  point  whence  it  started.  It  is  then  tied  to  the  other  suture.  In  this 
way  the  wound  is  closed  subcutaneously  and  without  the  exposure  of  a  knot. 


OBLITERATION  OF  DOUGLAS'  POUCH  FOR  RECTOCELE   (AUTHOR'S  METHOD) 

In  severe  cases  of  rectocele  the  most  painstaking  and  apparently  effective 
perineoplasty  is  sometimes  followed  by  a  recurrence.  This  is  due  to  a  deepening 
of  the  pouch  of  Douglas  caused  by  the  expanded  rectum,  so  that  even  when  the 
perineal  muscles  remain  intact  the  surgeon  may  find  in  the  course  of  time  that  a 
hernial  protrusion  is  beginning  to  roll  out  over  the  perineal  dam  under  the 
influence  of  abdominal  pressure.  Such  recurrences  usually  do  not  become  severe 
nor  do  they  often  cause  serious  subjective  symptoms.  Nevertheless,  the  reap- 
pearance of  a  lump  in  the  vagina  is  disconcerting  and  annoying  to  the  patient 
and  a  source  of  chagrin  to  the  surgeon.  Several  operators,  notably  D.  F.  Jones 
and  J.  G.  Clark,  have  successfully  obviated  this  difficulty  by  the  use  of  the 
Moschowitz  operation  originally  designed  for  prolapse  of  the  rectum.  We  have 
also  employed  this  operation  for  the  prevention  of  recurrent  rectocele  and  found 
it  of  practical  value.  In  a  complicated  reconstructive  operation,  however,  we 
have  found  the  Moschowitz  technic  somewhat  long  and  tedious,  and  we  have. 


644 


GYNECOLOGY 


therefore,  devised  the  following  rapid  method  of  obliterating  the  pouch  of  Douglas 
and  have  had  results  equally  as  good  as  with  the  Moschowitz  operation.  We 
recommend  it  only  for  cases  of  redocele  and  not  for  rectal  prolapse.  The  operation 
is  to  be  used  in  connection  with  some  form  of  suspension  of  the  uterus  or  with  the 
method  of  operating  for  procidentia  in  which,  following  supravaginal  hysterec- 
tomy, the  cervical  stump  is  attached  to  the  anterior  abdominal  wall. 


Fig.  292. — Closube  of  Douglas'  Pouch  (Author's  Method). 
The  uterus  is  drawn  upward  and  forward  as  far  as  possible.  The  sides  of  the  rectum  are 
seized  wth  AlHs'  clamps  at  the  points  where  the  uterosacral  ligaments  join  the  sides  of  the  rectum. 
The  clamps  are  inserted  into  the  pararectal  tissue  rather  than  into  the  rectal  wall  itself.  The 
clamps  are  then  brought  up  to  the  posterior  wall  of  the  cer\ax  just  above  the  origins  of  the  utero- 
sacral ligaments.  Sutures  passed  into  the  uterus  and  through  the  pararectal  tissue  suspend  the 
rectum  to  the  posterior  wall  of  the  cervix  at  these  two  points. 


The  patient  is  placed  in  a  steep  Trendelenburg  position.  The  intestines  are 
packed  back  with  gauze  sponges,  leaving  only  the  rectum  to  be  seen  in  the  pelvis. 
The  uterus  is  drawn  upward  and  forward  as  far  as  possible  so  as  to  give  a  good 
view  of  the  pouch  of  Douglas.     In  cases  of  marked  rectocele  the  pouch  will  be 


OPERATIONS    ON    THE    VAGINA 


645 


found  abnormally  deep.  The  course  of  the  uterosacral  ligaments  is  then  observed, 
and  at  the  points  where  they  join  the  rectal  wall  Allis'  clamps  are  apphed.  It 
will  be  found  that  the  clamps  may  be  set  firmly  into  the  pararectal  tissue  without 
including  the  rectal  wall,  and  that  when  traction  is  exerted  on  the  clamps  the  rec- 
tum may  be  lifted  under  considerable  tension  without  danger  of  tearing  the 


Fig.  293. — Closure  of  Douglas'  Pouch  (Author's  Method). 
The  openings  made  by  the  loops  of  the  uterosacral  ligaments  are  being  closed  by  running  sutures. 
The  closure  on  the  left  has  been  completed;  that  on  the  right  is  being  completed.     Interrupted 
sutures  attach  the  wall  of  the  rectum  to  the  posterior  wall  of  the  cervix. 


rectal  wall.  By  drawing  upward  on  the  two  Allis  clamps  the  anterior  wall  of  the 
rectum  is  then  lifted  to  as  high  a  point  as  possible  on  the  back  of  the  uterus. 
This  point  is  usually  at  about  the  level  of  the  uterine  attachments  of  the  utero- 
sacral ligaments.  Two  sutures  are  then  placed  through  the  pararectal  tissues 
included  in  the  clamps  and  into  the  uterine  wall.  The  sutures  are  tied  and  the 
ends  left  long  to  serve  as  tractors.     Thus  at  this  stage  it  will  be  seen  that  the 


646 


GYNECOLOGY 


rectum  is  drawn  tightly  up  and  suspended  by  two  sutures  to  the  back  of  the 
uterus.  On  the  sides  it  will  be  observed  that  each  uterosacral  ligament  forms  a 
loop  making  a  corresponding  opening  into  the  posterior  culdesac.  The  two 
openings  are  closed  by  running  catgut  sutures.  So  far  no  sutures  have  entered 
the  wall  of  the  rectum.  It  is  now  necessary  to  attach  the  rectum  to  the  uterus 
by  placing  interrupted  sutures  from  rectum  to  uterus  between  the  two  traction 
stitches.  In  placing  these  stitches  it  is  necessary  to  enter  the  muscularis  and 
submucosa  of  the  rectal  wall  in  order  to  secure  a  firm  attachment  of  adhesions 
to  the  uterine  surface.  AVhen  the  stitches  have  all  been  placed  it  will  be  found 
that  the  posterior  culdesac  is  completely  shut  off.  The  uterus  or  cervical  stump 
is  then  attached  to  the  anterior  abdominal  wall,  an  attachment  which  serves  to 
support  the  rectum.     There  is  no  danger  of  obstructing  the  lumen  of  the  bowel. 


ENLARGING   A   TIGHT   PERINEUM 

In  enlargmg  a  perineum  that  has  been  sewed  too  tightly,  or  that  has  shrunken 

from  senile  atrophy,  it  must  be  remem- 
bered that  the  stricture  is  due  to  a  cica- 
tricial contraction  of  the  superficial  parts 
of  the  perineum,  and. not  to  a  too  close 
union  of  the  muscles,  which  we  have 
seen  is  impossible. 

Usually  a  sharp  unyielding  band  of 
tissue  is  felt  at  the  introitus,  distention 
of  which  causes  pain  or  discomfort.  The 
operation  aims  to  do  away  with  this 
obstructing  band  and  to  create  a  funnel- 
shaped  elastic  introitus.  This  may  be 
done  as  follows:  A  transverse  incision 
is  made  through  the  scar  (Fig.  294).  All 
the  unyielding  cicatricial  bands  are  then 
dissected  out  subcutaneously  through  the 
initial  incision  (Fig.  295).  The  wound 
is  sewed  in  a  direction  at  right  angles 
to  the  way  in  which  it  was  incised  (Fig. 
296).  If  other  separate  cicatricial  bands 
or  cords  are  found  inside  the  vagina 
they  are  to  be  treated  in  the  same  way. 
It  is  a  significant  fact  that  the  peri- 
neal wounds  following  this  operation  heal 
with  some  difficulty,  owing  to  the  de- 
ficient blood-supply  to  the  wound.  The 
after-care   is,  therefore,    very   important. 

It  is  inadvisable  to  undertake  this  operation,  simple  as  it  seems,  without  full 

anesthesia. 


^j4v.& 


^^^ 


Fig.  294. — Enlarging  a  Tight  Perineum. 

A   transverse   incision  is  made   through  the 

sharp  cicatricial  posterior  fold  of  tissue. 


OPERATIONS    ON   THE    VAGINA 


647 


\xl3?.G^ 


Fig.  295.  — Enlarging  a  Tight  Perineum. 
Cutting  out  the  scar-tissue  by  subcutaneous  dis- 
section with  scissors. 


Fig.  296. — Enlarging  a  Tight  Pehineitm. 
Wound  closed,  leaving  funnel-shaped  introitus. 


OPERATION  FOR  COMPLETE  LACERATION  OF  THE  PERINEUM 

In  operating  for  perineal  tears  through  the  sphincter  the  principles  of  the 
Emmet  method  are  recommended,  with  modifications  to  suit, the  circumstances 
and  the  individual  technic  of  the  operator.  The  following  is  the  technic  em- 
ployed by  the  writer: 

The  patient  is  given  a  very  thorough  bowel  preparation,  beginning  the 
second  day  before  the  operation.  Before  beginning  the  operation  it  is  well  to 
pack  the  rectum  with  a  narrow  strip  of  gauze  to  prevent  the  escape  of  feces. 

The  first  part-  of  the  operation  is  performed  exactly  like  the  first  step  in  the 
ordinary  perineoplasty — ?'.  e.,  the  lateral  sulci  are  denuded  and  sutures  placed, 
unitmg  the  anterior  portion  of  the  levator  ani  muscles  (puborectales)  to^the  sides 
of  the  rectum.  This  in  some  cases  is  unnecessary,  for  it  often  happens  that  the 
perineal  separation  is  entirely  in  the  median  line  along  the  raphe  uniting  the 
lower  bellies  of  the  levators,  and  not  at  all  along  the  sides  of  the  rectum.  This 
is  usually  the  case  when  the  rectovaginal  septum  is  ruptured  for  any  consider- 
able distance.  When  there  is  no  separation  in  the  lateral  sulci  and  no  extensive 
tear  of  the  septum  a  simple  median  denudation  is  used  with  catgut  approxuna- 


648 


GYNECOLOGY 


tion  from  side  to  side,  care  being  taken  not  to  make  the  introitus  too  tight. 
If  there  is  extensive  rupture. of  the  rectovaginal  septum  a  special  technic  is 
required  (see  below) : 

The  type  of  case  most  commonly  seen  is  depicted  in  Fig.  297.     When  the 
internal  vaginal  part  of  the  operation  is  finished,  the  two  last  catgut  sutures 


vl-V-Oxuvies — ■ 


Fig.  297. — Operation  for  Complete  Lacer-^tiox  of  the  Perixeum. 
The  internal  part  of  the  perineum  operation  has  been  completed.     The  red  line  indicates  the 
outline  of  the  area  to  be  denuded  from  the  external  perineum.     It  is  carried  below  the  dimples  that 
mark  the  position  of  the  sphincter  ends.     This  denuded  area  should  not  be  made  so  wdde  that  the 
skin  edges  cannot  be  approximated  without  too  much  tension. 


which  close  the  lateral  sulci  are  left  long,  clamped  together,  and  held  firmly 
upward  by  an  assistant  .for  the  remainder  of  the  operation.  The  area  of  denuda- 
tion of  the  external  perineum  is  now  outlined.  Beginning  at  the  Bartholin 
duct  of  the  left  side,  a  light  mark  is  made  in  the  skin  with  the  scalpel  down  to 
the  dimple  which  indicates  the  retracted  end  of  the  sphmcter  muscle.  This 
line  should  be  curved  slightly  inward.  On  reaching  the  dimple  the  line  is 
carried  around  it,  and  across  to  the  dimple  that  represents  the  other  end  of  the 
torn  sphincter.    Tliis  transverse  incision  skirts  along  the  edge  of  the  connective- 


OPERATIONS    ON    THE    VAGINA 


649 


tissue  bridge  which  usually  forms  between  the  sphincter  ends,  and  should  be 
made  at  the  junction  of  the  skin  and  mucous  membrane  of  the  bowel  (Fig.  297). 


V.?.^<av)C5> 


\cv\cvcuUiTrv 


^'^®  xt^  S^Wncttx- 


Fig.  298. — Operation  for  Complete  Laceration  of  the  Perineum.  (Author's  teehnic.) 
The  field  of  operation  has  been  exposed  by  the  denudation  outlined  in  Fig.  297.  The  levator 
muscles  are  then  transfixed  with  tenacula  and  broiight  to  view.  A  figure-of-8  catgut  suture  (No.  0) 
is  placed  as  in  the  drawing.  The  ends  of  the  sphincter  muscle  are  transfixed  and  exposed  in  the  same 
way.  An  approximating  buried  catgut  figure-of-8  stitch  is  also  placed  in  the  ends  of  the  sphincter 
muscle.  Deeply  placed  silkworm-gut  sutures  are  then  introduced  from  side  to  side  beginning  at  the 
top,  as  in  the  Emmet  operation.  The  two  buried  catgut  sutures  are  not  tied  until  all  the  silkworm- 
gut  sutures  are  placed. 


On  reaching  the  dimple  of  the  right  side  the  line  of  demarcation  is  carried  around 
the  dimple  and  up  to  the  Bartholin  duct  of  that  side.  It  is  of  very  great  im- 
portance that  the  figure  thus  outlined  should  be  exactly  symmetric,  for  if  it  is 
not,  the  edges  of  the  wound  when  brought  together  from  side  to  side  will  not 
match.  Care  should  be  exercised  also  in  making  the  vertical  lines  not  to  draw 
them  too  far  apart,  otherwise  the  wound  edges  when  brought  together  will 
be  under  too  great  tension. 


650 


GYNECOLOGY 


When  the  figure  has  been  satisfactorily  marked  out,  the  intervening  skin 
is  removed  with  Emmet's  scissors.  All  scar-tissue  is  dissected  away  until  all 
the  parts  involved  in  the  operative  field  are  soft  and  plastic.  Tenacula  are  now 
introduced  deeply  into  the  bellies  of  the  separated  levators,  and  held  so  as  to 
bring  the  muscles  boldly  into  view.  Two  other  tenacula  seize  the  ends  of  the 
sphincter  muscle  and  expose  them  in  the  same  manner  (Fig.  298).  Figure-of- 
8  sutures  of  No.  0  chromicized  catgut  are  then  placed  in  both  the  levator  and 


N^.*?^  Gr — 

Fig.  299. — Operation  for  Complete  Laceration  of  the  Perineum.     (Author's  technic.) 
The  two  buried  figure-of-8  catgut  sutures  have  been  tied,  one  approximating  the  levator  ani 
muscles  and  the  other  uniting  the  ends  of  the  sphincter  muscle.     The  silkworm-gut  sutures  have 
been  placed  and  are  ready  to  be  tied. 

sphincter  muscles,  the  suture  ends  being  left  long  and  not  yet  drawn  taut. 
Beginning  then  at  the  top  of  the  wound  wilk worm-gut  stitches  are  placed  deeply 
into  the  fibers  both  of  the  levator  and  sphincter  muscles.  In  crossing  from  one 
side  to  the  other  over  the  chasm  made  by  the  laceration  the  silkworm-gut 
stitches  issue  from  and  enter  at  the  very  edge  of  the  rectal  mucous  membrane, 
but  not  including  it. 

When  all  the    stitches    have    been    properly    placed    the    two   figure-of-8 
stitches  which  are  to  be  buried  are  tied  firmly,  but  not  too  tightly,  and  the  ends 


OPEKATIONS    ON    THE    VAGINA 


651 


cut  short.  The  silkworm-gut  sutures  are  then  tied,  beginning  at  the  anal  end, 
the  ends  cut  and  shotted  (Fig.  300).  The  success  of  the  operation  depends 
chiefly  on  an  exact  approximation  of  the  sides  of  the  wound  without  undue 
tension,  for  if  this  is  not  attained,  non-union,  sepsis,  and  greater  or  less  destruc- 
tion of  the  wound  are  almost  sure  to  ensue. 


/  '<*«««,>• 


Fig.  300  — Operation  for  Complete  Tear  of  the  Perineum. 
The  silkworm-gut  sutures  have  been  tied,  cut,  and  shotted. 

During  convalescence  the  wound  requires  unremitting  attention  with  ex- 
pert nursing,  under  the  utmost  antiseptic  precautions.  The  bowels  are  kept 
closed  for  from  nine  to  twelve  days  and  then  moved  with  oil  catharsis.  The 
external  stitches  are  removed  on  the  ninth  day.  If  a  stitch  shows  signs  of  infec- 
tion before  that,  it  is  best  to  remove  it.  Catgut  for  the  external  stitches  is  inter- 
dicted. 

When  the  tear  extends  far  up  the  rectovaginal  septum,  the  denudation  of 
the  vaginal  portion  is  central  and  not  in  the  lateral  sulci.      The  denudation 


652 


GYNECOLOGY 


begins  above  the  upper  angle  of  the  wound,  and  is  carried  down  on  either  side 
to  the  Barthohn  ducts.  Only  a  small  amount  of  vaginal  tissue  should  be  removed 
in  the  region  of  the  introitus,  for  if  this  precaution  is  not  observed  there  is  much 
danger  of  closing  the  .perineum  too  tightly.. 


Fig.  301. — Operation  for  Complete  Laceration  of  the  Perineum.    (Warren's  "  apron"  method.^) 
The  sphincter  muscles  are  exposed  by  turning  down  a  flap  which,  when  sewed  up,  is  supposed 
to  prevent  the  wound  from  contamination  by  the  bowel.     The  operation  is  not  applicable  when  the 
rectovaginal  septum  has  been  torn. 


The  surest  results  are  gained  by  using  silkworm-gut  to  close  the  vaginal 
part  of  the  wound,  notwithstanding  the  annoyance  of  having  to  i^emove  them 
later,  catgut  not  being  dependable  in  these  cases.  Buried  rows  of  catgut  sutures, 
clQsing  the  wound  in  layers,  seem  at  the  time  of  operation  to  unite  the  wound 
with  great  strength,  but  the  catgut  is  treacherous,  and  in  the  long  run  the 
results  from  its  use  are  inferior  to  those  where  the  hard,  non-absorbable  suture 
has  been  employed. 

Rectovaginal  fistula  is  usually  associated  with  a  tear  through  the  sphincter 

^  The  principle  involved  m  the  apron  operation  was  devised  by  Dr.  J.  Collins  Warren  of  Boston- 
whose  paper  on  the  subject,  entitled  "New  Operation  for  Rupture  of  the  Perineum  through  the 
Sphincter,"  was  published  in  the  Transactions  of  the  American  Gynecological  Society  for  1883, 


OPERATIONS    ON   THE    VAGINA 


653 


muscle,  and  is  due,  as  a  rule,  to  the  healing  over  of  the  intervening  tissue.  It 
is  often  seen  in  cases  in  which  the  attending  obstetrician,  having  repaired  the 
tear  immediately  after  delivery,  has  secured  only  partial  healing  of  the  wound. 
Thus,  sometimes  one  sees  a  rectovaginal  fistula  where  the  sphincter  has  healed 
completely. 

In  operating  on  rectovaginal  fistulas,  if  the  sphincter  is  competent,  it  is  best 
to  attempt  the  closure  of  the  fistula  by  itself,  though  it  is  more  difficult  to  cure 
a  single  fistula  than  a  lacerated  sphincter.  If  the  sphincter  is  incompetent,  it 
is  advisable  to  cut  through  the  anus  to  the  fistula,  making  a  fresh  complete  tear. 

The  fistula  operation  may  be  done  in  layers  with  one  or  two  rows  of  buried 
catgut,  or  it  may  be  closed  with  a  single  row  of  interrupted  non-absorbable 
sutures,  silver  wire  or  silkworm-gut. 

We  have  found  the  latter  method  more  successfuk  The  opertion  is  practi- 
cally identical  with  that  for  vesicovaginal  fistula.  A  wide  denudation  is  made 
in  an  oval  shape  about  the  fistula,  the  direction  of  the  oval  being  made  longi- 
tudinal or  transverse,  so  that  the  tissues  may  be  brought  together  from  side  to 
side  with  as  little  tension  as  possible.  If  the  wound  is  to  be  sewed  in  layers 
the  rectal  mucous  membrane  is  separated  from  the  vaginal  membrane  for  a 
short  distance  about  the  fistulous  opening.  The  membranes  are  then  sewed 
separately  with  catgut. 

The  other  and  better  method  is  to  close  the  entire  wound  with  silver  wire, 
the  sutures  being  placed  well  out  from  the  margin  of  the  wound,  so  that  they 
may  act  as  a  sort  of  splint.     (See  Operations  for  Vesicovaginal  Fistulse.) 

OPERATIONS  FOR  VESICAL  FISTULA 

For  vesicovaginal  fistula  several  operations  have  been  devised.  For  small 
fistulse,  where  there  is  plenty  of  healthy  tissue  about  the  opening,  the  classical 


V/-?' 


to- 


Fig.  302. — Vesicovaginal  Fistula. 
Dissection  of  mucous  membrane  around  the  fistulous  opening. 

operation  of  Marion  Sims  is  entirely  satisfactory.     It  is-performed  in  the  follow- 
ing way: 


654 


GYNECOLOGY 


The  patient  is  either  in  the  lithotomy  or  in  the  Sims  position.  The  latter 
is  sometimes  preferable  where  the  fistula  is  high  up  toward  the  vault  of  the  vagina, 
as  is  frequently  the  case  when  the  injury  has  been  done  in  the  process  of  a  hys- 
terectomy. An  oval  denudation  is  made  with  fine  scissors  about  the  opening 
down  to  the  vesical  mucous  membrane,  special  care  being  taken  to  trim  off  the 
cicatricial  edge  of  the  bladder  opening.  The  denuded  margin  about  the  orifice 
should  be  as  wide  as  possible  without  causing  too  much  tension  when  the  edges 


Fig.  303.- — Vesicovaginal  Fistula. 
Wound  being  sutured  longitudinally  by  the  classical  method  of  closure. 

are  approximated,  usually  from  J  to  |  inch.  The  ends  of  the  oval  are  carried 
out  still  further  from  the  opening.  The  direction  of  the  denuded  oval  is  deter- 
mined by  the  individual  case,  and  is  made  longitudinal,  transverse,  or  even 
obhque  in  relation  to  the  vaginal  axis,  according  to  which  way  the  tissues  can 
be  brought  together  with  the  least  tension.  As  a  rule,  the  transverse  denuda- 
tion is  the  most  favorable.  When  the  denudation  has  been  cleanly  and  s>aii- 
metrically  made,  interrupted  sutures  are  introduced  from  side  to  side,  being 
carried  well  into  the  vaginal  tissues  and  down  to  the  edge  of  the  bladder  mucosa, 


OPERATIONS    ON   THE   VAGINA 


655 


but  not  including  it  (Fig.  303).  The  suture  material  is,  preferably,  fine  silver 
wire,  carried  by  silk  guides,  which  are  threaded  on  fine  full-curved  needles. 
It  is  advisable  to  begin  at  the  center  of  the  wound  and  work  each  way,  so  that 
there  will  be  no  error  in  approximating  the  vaginal  mucous  membrane  that 
covers  the  fistula.  The  stitches  should  be  fairly  close  together  and  carried  for 
a  considerable  cUstance  to  each  side  of  the  opening,  so  that  even  when  the 
fistula  is  small  eight  or  ten   sutures   are   usually  required.      The   silver-wire 


^V^^feJBi 


\Ni.?6 


Fig.  304. — Vesicovaginal  Fistula. 
Wound  being  sewed  transversely  by  the  classical  method  of  closure. 

sutures  are  twisted,  bent  to  one  side,  and  cut  off  about  h  inch  long.  They  are 
removed  in  fifteen  to  seventeen  days.  During  convalescence  for  the  first  week 
or  ten  days  the  patient  should  not  be  allowed  to  accumulate  more  than  4  ounces 
in  her  bladder.  Two  or  three  catheterizations  may  at  first  be  necessary,  after 
which  the  patient  is  usually  able  to  urinate  voluntarily.  Strict  watch  of  the 
urinations  should  be  kept  and  the  patient  wakened  at  regular  intervals  during 
the  night.     If  catheterization  is  necessary,  it  should  be  done  only  by  experienced 


656 


GYNECOLOGY 


hands.  If  the  patient  is  conscientiously  tended  in  this  manner  the  results  are 
far  better  than  those  attained  by  the  use  of  self -retaining  catheters,  which  should 
be  avoided  if  possible. 

A  second  method  for  treating  vesicovaginal  fistula  is  that  of  dissection  and 
cleavage  of  the  vaginal  and  bladder  walls,  and  sewing  the  wound  in  separate 
layers.  This  method  is  especially  applicable  to  cases  in  which  there  has  been 
a  considerable  loss  of  tissue,  so  that  the  approximation  of  the  wound  edges  by 


N^.T.Coxcv»es.--«- 

Fig.  305. — Operation  for  Vesicovaginal  Fistula. 
Incision  for  the  method  of  closing  by  layers. 


the  Sims  method  cannot  be  accomplished  without  too  great  tension.  An  incis- 
ion' is  made  with  a  sharp  knife  (Fig.  305)  and  the  bladder  and  vaginal  walls 
separated  about  the  fistulous  opening.  This  dissection  is  carried  out  until  the 
edges  of  the  vesical  wound  can  be  approximated  with  forceps  without  tension. 
The  edges  of  the  bladder  wound  are  freshened  by  trimming  them  with  scissors. 
The  vesical  layer  is  closed  by  a  continuous  fine  catgut  suture  introduced 
by  the  Lembert  method.     The  vaginal  plane  is  closed  by  interrupted  non- 


OPERATIONS    ON   THE    VAGINA 


657 


absorbable  sutures,  preferably  of  silver  wire,  applied  as  in  the  Sims  operation. 
It  is  often  advantageous  to  sew  the  two  layers  so  that  the  two  wounds  will  not 
coincide,  but  cross  each  other  in  direction.  Sometimes  the  vesical  plane  can 
be  closed,  but  the  vaginal  flaps  cannot  be  coaptated  without  too  great  strain. 
Kelly's  method  in  this  emergency  is  to  sew  the  vesical  mucous  membrane  of 
one  side  of  the  wound  to  the  combined  edges  of  the  bladder  and  vagina  of  the 


\l.?.C^-a\i«.s--- 


FiG.  306. — Oper.'\.tion  fob  Vesicovaginal  Fistula. 
Sewing  up  by  layers.     The  first  line  of  sutures  inverts  the  vesical  mucous  membrane.     A  con- 
tinuous Lembert  stitch  of  fine  chromic  gut  is  employed  for  the  bladder  wall.     Interrupted  silver  wire 
or  silkworm-gut  sutures  close  the  vaginal  wound. 

other  side  of  the  wound.     This  leaves  a  raw  area  which,  Kelly  states,  is  soon 
covered  with  epithelium. 

A  third  method  of  treating  vesicovaginal  fistula,  and  one  especially  recom- 
mended by  Albarran,  is  the  operation  of  Braquehaye.  An  incision  is  made  as 
in  Fig.  305,  leaving  a  margin  of  vaginal  mucous  membrane  about  the  fistulous 
orifice.  If  the  fistula  is  in  a  position  difficult  of  access,  much  more  room  can 
be  gained  by  making  a  paravaginal  incision,  such  as  is  described  on  page  728 
in  performing  a  vaginal  hysterectomy  for  cancer. 

42 


658 


GYNECOLOGY 


The  walls  of  the  vagina  and  bladder  are  then  separated,  as  in  the  preceding 
operation.  The  small  area  of  mucous  membrane  left  about  the  fistulous  opening 
is  dissected  up  so  as  to  form  a  collarette,  which  is  inverted  into  the  bladder.  In 
this  way  denuded  surfaces  are  in  contact  with  each  other  at  the  -opening,  a  con- 
dition favorable  for  closure.  The  inverted  orifice  is  closed  in  by  a  reduphcating 
continuous  Lembert  stitch,  as  shown  in  Fig.  309.  The  vaginal  mucous  mem- 
brane is  closed  by  interrupted  sutures,  as  in  the  two  preceding  operations,  it 
being  advantageous  to  have  the  two  suture  lines  cross  at  an  angle. 


Fig.  307.: — Operation  for  Vesicovaginal  Fistula  Closure  by  Layers. 
The  bladder  wall  has  been  sewed  with  a  continuous  Lembert  stitch  of  fine  chromic  gut.     The  vaginal 

wall  is  being  closed  with  silver  wire. 


In  extreme  cases,  where  there  has  been  a  profound  destruction  of  the  tissues, 
such  as  the  almost  complete  disappearance  of  the  vesicovaginal  septum,  the 
condition  may  be  treated  by  closing  up  the  vagina  below  the  opening  (colpo- 
cleisis).  By  this  method  the  upper  part  of  the  vagina  becomes  an  integral  part 
of  the  bladder,  so  that  if  the  patient  has  not  reached  the  menopause  the  menstrual 
blood  passes  into  the  bladder.     The  disadvantages  of  the  operation  are  obvious. 


OPERATIONS    ON    THE    VAGINA 


659 


Vesicocervico vaginal  (or  juxtacervical)  fistula  (Fig.  310)  cannot  be  satis- 
factorily denuded  in  the  manner  of  vesicovaginal  fistulse  described  above.  In 
these  cases  the  orifice  of  the  fistula  is  usually  embedded  in  an  immovable  mesh 
of  cicatricial  tissue,  making  plastic  operations  well  nigh  impossible.  The  best 
plan  here  is  to  make  a  transverse  incision,  and  separate  the  vaginal  vault  and 
bladder  from  the  cervix.  This  exposes  the  opening  in  the  bladder  wall,  which 
may  then  be  closed  by  a  continuous  Lembert  suture.  The  method  is  illustrated 
in  Fig.  314  (adapted  from  Kelly). 


Fig.  308. — Braquehaye's   Operation  for  Vesicovaginal  Fistula,    Modified   by   Albarran- 
Turning  in  the  cuff  around  the  fistula  (adapted  from  Albarran) . 


In  vesico-uterine  (intracervical)  fistula  the  opening  is  into  the  cervical  canal 
aiid  cannot  be  seen.  The  position  of  the  fistula  can  be  determined  by  intro- 
ducing one  probe  into  the  opening  from  the  bladder  and  one  into  the  cervical 
canal,  the  height  of  the  opening  being  detected  by  the  chcking  of  the  two  metal 
instruments. 

If  the  opening  is  low,  the  fistula  may  be  reached  by  a  transverse  vaginal 


660 


GYNECOLOGY 


Fig.  309. — Braquehate's  Operation  for  Vesicovaginal  Fistula. 
Method  of  closure.     The  lines  of  suture  of  the  two  layers  will  be  at  right  angles. 


Fig.  310. — Vesicocervicovaginal  (or  Juxtacervical)  Fistula. 
The  fistulous  opening  is  near  the  cervix. 

incision,  with  separation  of  the  bladder  from  the  cervix,  as  in  the  operation  for 
juxtacervical  fistula  described  above.     If  the  communication  between  uterus 


OPEIL'^TIONS    ON   THE   VAGINA 


661 


Fig.  311. — Repair  of  Juxtacervical  Fistula. 
The  bladder  has  been  separated  from  the  cervix.     The  bladder  wall  has  been  closed  by  a  Lembert 
running  stitch,  which  inverts  the  mucous  membrane  toward  the  lumen  of  the  bladder.     The  vaginal 
membrane  has  not  yet  been  sutured. 


Fig.  312. — Repair  of  Juxtacervical  Fistul.\. 
Both  the  bladder  wall  and  the  vaginal  wall  have  been  closed  by  separate  layers  of  sutures. 


662 


GYXECOLOGY 


and  bladder  is  well  up  in  the  cen-ix  the  conchtion  is  best  approached  by  the 
abdominal  route,  the  details  of  the  operation  being  as  follows : 

Median  abdominal  incision,  with  the  patient  in  the  Trendelenburg  petition. 
The  uterus  is  held  well  back  by  traction  forceps  and  a  transverse  incision  made 
through  the  utero vesical  reflection  of  peritoneum.  The  bladder  is  then  separated 
from  the  cervTX  until  the  vesical  opening  is  completely  isolated  -uith  plenty  of 
free  bladder  tissue  about  it  to  aUow  for  suturing.  The  wound  is  closed  by  one 
or,  if  possible,  two  rows  of  Lembert  sutures. 


Fig.  313. — JuxTACEKVicAii  Fisttjxa.     The  Ixcisiox. 


The  opening  into  the  uterine  canal  may  be  sutured  or  not.  If  the  edges 
are  freshened,  it  vnW  heal  spontaneously,  and  if  not  closed  too  tightly  acts  as  a 
channel  for  drainage  in  case  the  bladder  wound  does  not  heal  properly. 

Vesico-uterine  fistulse  may  be  closed  indirectly  by  denuding  and  suturing  the 
cer\ucal  hps  (hysterostomatocleisis),  by  which  procedure  the  uterus  is  made  to 
drain  into  the  bladder.  The  operation  is  not  recommended  unless  other  methods 
are  not  feasible. 


OPERATIONS    ON   THE   VAGINA 


663 


.  _         v^/RGx axle's. 

ttfe'  'ti  /mT  11  iia^l^i' 

Fig.  314. — Juxtacervical  Fistula. 
The  bladder  has  been  freed  from  the  cervix.     The  opening  in  the  bladder  is  being  closed  in  by  a 

running  Lembert  suture. 


Fig.  315. — Uterovbsical  Fistula. 
There  is  a  fistulous  communication  between  the  bladder  and  the  canal  of  the  cerAox. 


664 


GYNECOLOGY 


Fig.  316. — Repair  of  Uterovesical  Fistul.^  by  the  Abdominal  Route. 
An  opening  has  been  made  through  the  peritoneal  reflection,  exposing  the  fistulous  tract. 


Fig.  317. — Acquired  Atresia  of  the  Vagina. 
The  later  effect  of  simple  incision  without  complete  removal  of  the  occluding  membrane.     The 
incision  closes  down  to  a  pinhole  opening  which  affords  very  incomplete  drainage  of  the  uterus  and 
vagina.     Foul  decomposing  material  collects  in  the  vagina  and  discharges  continuously  or  periodically 
through  the  small  opening  in  the  membrane. 


OPERATIONS    ON   THE   VAGINA 


665 


OPERATIONS  FOR  ATRESIA  OF  THE  VAGINA 

The  operation  for  atresia  in  girls,  where  there  is  partial  or  complete  retention 
of  menstrual  blood,  is  attended  with  considerable  danger  of  fatal  sepsis,  and 
every  precaution  should  be  taken  to  prevent  infection.  When  hematocolpos 
and  hematometra  are  present  the  occluding  membrane  is  first  freely  incised, 
the  cavities  of  the  vagina  and  uterus  evacuated  and  carefully  irrigated.  This 
does  not  complete  the  operation,  for  the  opening  made  by  such  an  incision 
sometimes  closes  up  entirely,  but  more  often  results  in  one  or  more  pinhole 


FiG.  318.— Acquired  Atresia  of  the  Vagina. 
Dissecting  out  the  occluding  membrane  mth  scissors. 


apertures  through  which  the  menstrual.blood  may  partially  flow  (Fig.  317). 
A  certain  amount  of  mucus  and  blood  is  dammed  back  into  the  vagina,  becomes 
foully  infected,  and  produces  dire  results.  In  order  to  leave  the  vagina  in  a 
permanently  normal  condition  the  occluding  membrane  should  be  completely 
dissected  out  and  the  wound  edges  approximated  with  great  care.  Such  a  wound 
will  heal  by  first  intention,  even  in  the  face  of  a  badly  septic  discharge.  The 
details  of  the  operation  for  dissecting  out  an  occluding  membrane  are  as  fol- 
lows: 


666 


GYNECOLOGY 


After  the  septum  has  been  incised  and  the  contents  of  the  space  beyond  have 
been  removed,  there  should  be  a  thorough  cleansing  of  the  parts,  as  stated 
above.  The  edges  of  the  septum  should  then  be  trimmed  flush  with  the  walls 
of  the  vagina  (Fig.  318).  All  scar-tissue  should  be  removed  so  as  to  prevent  a 
future  contraction.  When  the  septum  has  been  completely  cleared  away  it 
will  be  found  that  there  remains  a  denuded  area  which  extends  like  a  ring  around 
the  inner  circumference  of  the  vagina.     The  mucous  membrane  of  the  upper 


Fig.  319.— Acquired  Atresia  of  the  Vagina. 

The  transverse  septum  has  been  dissected  out  and  the  upper  portion  of  the  mucous  membrane  of  the 

vagina  united  to  the  lower  by  interrupted  catgut  sutures. 

portion  of  the  vagina  is  then  drawn  down  and  approximated  to  that  of  the 
lower  portion  by  interrupted  catgut  sutures  (Fig.  319).  Such  an  operation 
should  restore  perfectly  the  normal  cahber  of  the  vagina,  and  is  not  followed  by 
a  tendency  to  the  development  of  a  stricture.  The  use  of  antiseptic  douches 
twice  or  three  times  daily  is  begun  the  day  after  the  operation,  and  should,  be 
kept  up  until  the  discharge  completely  disappears. 


OPERATIONS    ON   THE   VAGINA 


667 


OPERATIONS  FOR  ABSENCE  OF  VAGINA 

The  creation  of  an  artificial  vagina  may  be  done  either  by  the  method  of 
employing  a  loop  of  gut  or  by  the  turning  in  of  skin-flaps  from  the  surrounding 

parts. 

A  technic  devised  and  employed  successfully  by  the  author  in  one  case  is 

as  follows : 

The  patient  is  placed  in  the  perineal  position.  A  superficial  transverse  incis- 
ion is  made  just  below  the  urethra.  Through  this  transverse  slit  the  bladder 
and  rectum  are  slowly  dissected  apart  with  the  finger.  The  forefinger  of  the 
left  hand  should  be  kept  in  the  rectum,  and  some  blunt  instrument,  like  a 


Fig.  320. — Congenital  Absence  of  Vagina. 


urethral  dilator,  should  be  held  in  the  bladder  by  an  assistant.  The  dissection 
is  carried  out  by  the  right  forefinger,  the  left  forefinger  behind  and  the  blunt 
instrument  in  front  acting  as  guides  to  prevent  tearing  into  the  wall  of  the 
rectum  or  bladder.  In  this  way  an  artificial  opening  can  be  made  of  the  exact 
proportions  of  the  normal  vagina.  Care  should  be  exercised  not  to  enter  the 
abdominal  cavity.  The  next  step  is  to  line  this  cavity  with  a  pouch  of  skin 
made  up  of  flaps  turned  in. from  the  surrounding  parts.  To  accomplish  this, 
the  two  labia  minora  are  dissected  off,  from  above  downward,  in  such  a  manner 
as  to  leave  a  pedicle  sufficiently  large  to  furnish  good  circulation.  The  two  sur- 
faces are  then  split  apart  so  that  two  paddle-shaped  fiaps  remain.  There  should 
then  be  dissected  from  the  inner  side  of  the  thigh  two  similar  flaps  which  have 
their  bases  at  the  two  lower  corners  of  the  artificial  opening.     All  four  flaps 


668 


GYNECOLOGY 


^^;__4- 


V/.p.GcrtxMes. 


Fig.  321. ■ — An  Operation  for  Absence  of  the  Vagina  (Author's  Method). 
An  artificial  opening  has  been  made  between  bladder  and  rectum,  corresponding  to  the  size  of  a 
normal  vagina.  Four  skin-flaps  have  been  sewed  together  over  an  old-fashioned  glass  speculum  in- 
verted. The  two  upper  flaps  are  the  two  labia  minora  partially  amputated  and  spread  out  flat.  The 
two  lower  flaps  are  turned  in  from  the  th'gh.  The  sewing  of  the  seams  is  not  completed  until  after 
the  glass  form  has  been  removed  and  supporting  stitches  placed  in  the  vault  of  the  new  vaginal 
opening. 


OPERATIONS    ON    THE   VAGINA 


669 


Tk;.  :■;_'_'.— Operation' foe  Congenital  Absence  of  Vagina. 

The  glass  form  has  been  removed  and  the  seams  of  the  pouch  completely  sewed.     The  untied 

sutures  seen  issuing  from  the  pouch  were  p^e^-iousiy  passed  through  the  vault  of  the  artificial  opemng 

made  between  the  bladder  and  rectum.     The  pouch  is  inverted  into  the  artificial  opening  and  the 

stitches  tied  so  as  to  prevent  any  prolapse  of  the  pouch  before  it  heals  to  the  raw  surface  of  the  opemng. 


are  then  sewed  together  over  a  glass  form,  as  shown  in  the  cut  (Fig.  321).    Before 
the  flaps  are  sewed  together  several  catgut  sutures,  with  the  ends  left  long, 


670  GYNECOLOGY 

should  be  placed  in  the  vault  of  the  artificial  cavity.  When  the  skin  pouch 
has  been  nearly  completed,  the  glass  form  is  removed  and  the  catgut  sutures  are 
brought  out  through  the  skin  pouch.  The  pouch  is  then  inverted,  and  the 
sutures  are  tied  in  such  a  manner  that  the  pouch  fits  snugly  into  the  artificial 
cavity. 

SCHUBERT'S  Operation  for  Absence  of  Vagina 

Schubert  has  devised  a  method  of  creating  an  artificial  vagina  from  the 
rectum.     He  performs  his  operation  as  follows: 

The  patient  is  placed  in  the  right  Sims  position.  The  hymen  is  first  com- 
pletely dissected  away,  leaving  a  circular  denuded  area  of  tissue  where  the 
introitus  is  usually  situated.  The  sphincter  is  then  dilated  and  a  circular  incis- 
ion made  about  the  anus.  Through  this  incision  the  rectum  is  dissected  from 
the  sphincter  muscle  for  the  distance  of  about  3  cm.  without  injuring  the  muscle. 

Beginning  then  at  a  point  5  cm.  above  the  anus  a  10  cm.  incision  is  made 
over  the  coccyx,  which  is  extirpated.  The  pelvic  fascia  is  divided  by  a  longi- 
tudinal incision.  Through  this  opening  the  rectum  is  drawn  out  after  first 
being  freed  from  its  connective-tissue  attachments.  The  rectum  must  be  suffi- 
ciently freed  so  that  the  upper  segment  of  the  loop  can  be  drawn  clown  to  the 
anus.  The  loop  of  rectum  drawn  out  through  the  opening  at  the  coccjoi  is  now 
pinched  with  intestinal  clamps  and  divided.  The  cut  end  of  the  lower  segment 
is  firmly  closed  by  sutures.  The  culdesac  of  gut  thus  formed  is  attached  as 
high  as  possible  to  the  sacrospinal  ligament. 

The  finger  is  then  pushed  through  the  opening  in  the  vulva  made  by  dis- 
secting off  the  hymen,  and  an  opening  in  the  tissue  made  toward  the  coccygeal 
wound.  The  canal  thus  made  is  widened  so  that  it  will  easily  admit  two  fingers. 
The  anal  end  of  the  rectum  which  was  first  dissected  away  from  the  sphincter 
is  drawn  up  through  the  newly  made  orifice  and  attached  there  by  interrupted 
sutures  through  the  margin  of  the  skin.  The  new  vagina  thus  constructed, 
therefore,  consists  of  the  lower  end  of  the  rectum,  which  now  extends  from 
the  new  opening  in  the  vulva  to  the  blind  culdesac  attached  to  the  sacrospinal 
ligament. 

The  operation  is  concluded  by  drawing  the  upper  cut  end  of  the  rectum 
down  through  the  sphincter  and  suturing  it  there  to  the  skin  margin. 

The  advantages  of  this  operation  over  the  Baldwin  method  are  that  it  is 
less  dangerous  to  life,  and  that  the  secretions  from  the  bowel  mucosa  are  less 
irritating. 

BALDWIN'S   Operation  for  Absence  of  Vagina 

First  Step. — A  transverse  incision  is  made  at  the  hymen  (Fig.  323).  The 
plane  of  cleavage  between  the  rectum  and  bladder  is  sought,  and  the  two  organs 
separated  by  blunt  dissection  until  the  peritoneum  is  reached.  A  cavity  is 
thus  made  corresponding  in  width  and  depth  to  a  roomy  vagina  (Fig.   324). 


OPERATIONS    ON   THE   VAGINA 


671 


An  iodoform  gauze  tampon  is  inserted  in  this  artificial  opening  and  the  patient 
put  in  the  Trendelenburg  position  for  laparotomy. 

Second  Step. — Laparotomy. — A  median  incision  is  made  and  the  pelvis  in- 
spected. Rudimentary  internal  genitalia  will  be  found,  usually  in  the  form  of 
a  double  uterus.  The  two  uteri  should  be  separated  by  incision,  and  if  one 
contains  a  lumen,  it  should  be  amputated.  The  junction  of  the  ileum  with  the 
cecum  is  then  sought.     At  the  distance  of  about  12  inches  from  the  cecum  the 


Fig.  323.' — Operation  for  Congenital  Absence  of  the  Vagina. 
The  red  line  shows  the  transverse  inciBion  made  preliminary  to  separating  the  bladder  from  the  rectum. 

mesentery  of  the  ileum  is  found  to  be  especially  long.  Beginning  at  this  point, 
about  10  inches  of  the  ileum  is  resected  and  the  ends  of  the  resected  portion 
closed  by  a  purse-string  suture.  The  two  ends  of  the  ileum  are  now  united  by  a 
lateral  anastomosis  in  front  of  the  mesentery  of  the  detached  segment  (Fig.  326). 
A  silk  hgature  is  passed  around  the  detached  portion  of  bowel  at  its  middle 
point,  to  be  used  as  a  tractor  (Fig.  326).  An  assistant  removes  the  gauze 
tampon  from  the  opening  previously  made  between  rectum  and  bladder  and 
inserts  a  long  clamp,  which  he  pushes  against  the  layer  of  peritoneum  interven- 


672 


GYNECOLOGY 


Fig.  324.-^Operation  for  Artificial  Vagina. 
An  opening  has  been  made  between  the  bladder  and  rectum  as  far  as  the  peritoneum. 


Fig.  325. — Operation  for  Artificial  Vagina  (Baldwin's  Method). 
A  portion  of  the  small  intestine  has  been  resected,  leaving  the  mesentery  attached. 


OPERATIONS    ON   THE   VAGINA 


673 


ing  between  the  opening  and  the  peritoneal  cavity.  With  this  clamp  as  a  guide 
an  opening  is  made  by  the  operator  through  the  peritoneum,  great  care  being 
exercised  not  to  injure  the  bladder  or  rectum.  The  traction  Hgature  is  now 
grasped  by  the  clamp,  which  by  this  means  draws  the  detached  segment  of 


Fig.  326. — Operation  for  Artificial.  Vagina. 

Lateral  anastomosis  uniting  the  ends  of  the  resected  gut.     The  free  loop  of  intestine  with  mesentery 

attached  is  being  drawn  down  by  a  guide  ligature. 


bowel  down  into  the  artificial  opening  in  the  form  of  a  loop.  The  peritoneum 
is  sewed  with  fine  catgut  sutures  around  the  ends  of  the  loop.  The  abdominal 
wound  is  closed. 

Third  Step. — The  loop  of  bowel  is  drawn  down  until  it  extrudes  from  the  new 


43 


674 


GYNECOLOGY 


Fig.  327. — Operation  for  Artificial  Vagina  (Baldwin's  Method), 
A  loop  of  intestine  has  been  resected,  leaving  the  mesentery  attached.     Lateral  anastomosis  has 
been  performed,  uniting  the  ends  of  the  resected  gut.     The  free  loop  of  intestine  has  been  drawn  down 
through  the  opening  made  between  bladder  and  rectum  (after  Stoeckel). 


XevMMciQi.na 


Fig.  328. — Operation  for  Artificial  Vagina. 
The  free  loop  of  intestine  has  been  drawn  down  into  the  opening  made  between  bladder  and 
rectum.     It  has  been  stitched  in  place  and  an  opening  made  in  the  wall.    The  septum  made  by  the 
loop  may  be  incised  later. 


OPERATIONS    ON   THE   VAGINA 


675 


introitus.  The  outer  wall  of  the  gut  is  incised  and  the  edges  stitched  to  the 
skin  around  the  hjaneneal  opening.  The  two  legs  of  the  loop  are  twisted  so  that 
the  left  lies  anterior  and  the  right  posterior.  In  this  way  a  double  vagina  is 
formed  (Fig.  327).  The  walls  of  the  gut  which  form  the -septum  between  the 
two  vaginal  canals  become  adherent  in. the  course  of  time.  This  septum  may- 
be incised  later,  so  that  a  simple  vagina  is  created.  It  should  be  remembered 
that  the  mucous  membrane  of  the  new  vagina  continues  to  secrete,  and  that  it 
constitutes  an  absorbing  surface,  to  which  certain  kinds  of  vaginal  douches, 
like  corrosive  sublimate,  may  be  a  dangerous  poison.  The  secretion  is  influenced 
by  diet,  being  greatly  increased  by  albuminous  food. 


VAGINAL  CELIOTOMY 
Anterior  and  Posterior  Colpotomy 

The  vaginal  route  for  the  surgical  treatment  of  such  conditions  as  uterine 
fibroids,  ovarian  tumors,  pelvic  adhesions,  extra-uterine  pregnancy,  etc.,  is  now 


Fig.  329. —Anterior  Colpotomy  for  Pelvic  Operations  by  the  Vaginal  Route. 

comparatively  little  used,  and  is  for  the  most  part  confined  to  operations  for 
prolapse,  like  those  of  Watkins  and  Goffe,  and  occasionally  to  vaginal  hysterec- 
tomies. 


676 


GYNECOLOGY 


The  pelvis  may  be  entered  either  by  opening  the  anterior  or  posterior  wall 
of  the  vagina. 

Anterior  colpotomy  is  performed  in  the  following  way:  The  anterior  lip  of 
the  cervix  is  seized  with  traction  forceps,  and  the  uterus  drawn  strongly  down 
toward  the  introitus.  The  peritoneal  cavity  may  be  entered  either  through  a 
transverse  incision  made  at  the  junction  of  the  bladder  and  cervix  or,  pre- 
ferably, by  a  J.-shaped  opening.  By  the  latter  method  an  incision  is  made 
from  a  short  distance  below  the  urethra  to  the  cervix.  The  vaginal  wall  on 
each  side  is  then  loosened  from  the  bladder  and  a  cross  incision  made  at  right 


Fig.  330. — Posterior  Colpotomy. 
Crucial  incision  through  the  posterior  vaginal  wall  into  the  culdesac  of  Douglas. 


angles  to  the  first,  at  the  level  of  the  junction  of  the  bladder  with  the  cervix. 
The  two  flaps  are  further  separated  from  the  bladder  wall  by  blunt  dissection 
and  drawn  outward  by  traction  hooks.  The  bladder  is  then  stripped  back 
from  the  cervix,  care  being  taken  not  to  injure  its  wall.  When  the  peritoneal 
reflection  is  reached  it  is  seized  with  tissue  forceps  and  incised,  the  incision 
being  carried  to  each  side  into  the  broad  ligaments  as  far  as  possible.  The 
peritoneum  of  the  bladder  reflection  is  lifted  up  and  cut  in  the  median  line 
as  far  as  the  fundus  of  the  bladder  (Fig.  329).  Into  the  opening  thus  made  is 
inserted  a  speculum  which  draws  the  bladder  up  to  the  symphysis.  The  next 
step  is  the  •delivery  of  the  uterus  and  adnexa  through  this  opening.    The  traction 


OPERATIONS    ON   THE   VAGINA  -.677 

forceps  on  the  anterior  cervical  lip  is  forced  back  toward  the  posterior  wall  of 
the  vagina  so  as  to  ant  evert  the  uterus.  The  anterior  wall  of  the  uterus  is 
seized  with  double  hooks  and  the  fundus  drawn  out  of  the.  wound.  As  the  uterus 
is  dehvered,  the  tubes  and  ovaries  come  into  view  and  shp  out  of  the  wound 
unless  restrained  by  adhesions.    The  desired  operation  can  then  be  performed. 

Posterior  Colpotomy. — The  technic  of  posterior  colpotomy  is  somewhat 
simpler  than  the  anterior  operation,  but  according  to  those  who  employ  the 
vaginal  route,  notably  Goffe,  it  is  much  less  useful  for  the  average  case. 

The  posterior  hp  of  the  cervix  is  grasped  mth  traction  forceps  and  drawn 
forward  toward  the  symphysis.  The  posterior  vaginal  wall  is  thus  put  on  the 
stretch.  A  longitudinal  incision  about  5  cm.  long  is  made,  beginning  at  the 
portio  and  running  back  in  the  median  hne.  The  incision  is  carried  through  the 
vaginal  wall,  the  loose  cellular  tissue,  and  into  the  peritoneal  Cavity.  In  order 
to  enlarge  the  opening  thus  made,  two  lateral  cuts  may  be  made  at  right  angles 
to  the  original  incision  (Fig.  330).  To  deliver  the  uterus  and  adnexa  the  poste- 
rior wall  of  the  uterus  is  seized  with  double  hooks  and  drawn  backward  out  of 
the  vaginal  wound. 


OPERATIONS   FOR  UTERINE   MALPOSITION 


Operations  for  retroversion 
olshausen's  operation  for  suspension  of  the  uterus  (author's 

TECHNIC) 

A  SHORT  median  suprapubic  incision  is  made.  The  appendix  is  inspected 
and  removed  as  a  routine  measure.  The  edges  of  the  peritoneum  and  fascia  on 
each  side  of  the  wound  are  clamped  in  order  to  facihtate  the  passage  of  stitches. 
Each  round  hgament  is  grasped  near  the  uterus  with  a  half-length  clamp,  which 
is  pressed  tightly  enough  to  raise  the  ligament,  but  not  to  lacerate  it.     A  hga- 


:;^,^.Ca<oM« 


Fig.  331.^0lshausen's  Operatiox.     First  Step. 

The  round  ligament  is  lightly  grasped  with  half-length  forceps  near  the  fundus.     The  silk  suture  is 

introduced  so  as  to  include  the  whole  thickness  of  the  ligament. 

ture  of  No.  7  braided  silk  doubled  is  then  passed  under  the  right  round  ligament 
at  a  distance  from  the  uterus  which  is  determined  by  the  size,  weight,  desire 
for  -mobility,  etc.,  it  being  remembered  that  the  nearer  the  uterus  it  is  placed 
the  greater  will  be  the  supporting  power  and  the  less  the  mobility.  The 
average  distance  is  ^  inch.  The  suture  is  carried  through  the  abdominal  wall, 
including  the  peritoneum,  muscle,  and  fascia,  and  then  returned  to  the  perito- 
neal cavity,  including  a  bight  in  the  wall  of  about  jto  I  inch.  The  ligature  is 
placed  in  the  abdominal  wall  at  a  distance  from  the  median  line  corresponding 
to  the  point  where  the  base  of  the  round  ligament  would  touch  the  peritoneum 
if  the  uterus  were  brought  up  to  the  abdominal  wall.     The  level  at  which  it  is 

678 


OPERATIONS    FOR    UTERINE    MALPOSITION 


679 


placed  is  also  determined  in  the  same  v^slJ,  except  that  if  there  is  much  pro- 
lapse or  if  it  is  desired  to  correct  an  anteflexion,  the  attachment  is  made  some- 


Fig.  332.— Olsh-^usex's  Oper-^tiox  Viewed  from  Within  the  Abdomev. 
Tight  ligature  of  the  ligaments  to  the  anterior  abdominal  wall  creates  two  firm  adhesions  at  the 
points  of  contact.     The  anatomic  result  is  practicaUy  the  same  as  that  of  Gilliam's  operation. . 

what  higher  on  the  abdominal  wall  than  would  correspond  to  the  natural  position 
of  approximation. 


it-ore/. 


Fig.  333. — Olsh-^usen's  Operation. 

Showing  the  lavers  through  which  the  supporting  sutures  are  carried.     Note  that  they  include  the 

peritoneum,  muscle,  and  fascia,  and  are  tied  on  the  inside  of  the  abdomen. 

After  placing  the  Hgature  on  the -right,  the  left  one  is  introduced  in  the  same 
way  at  a  sjmmietric  point  on  the  other  side  of  the  wound.     The  ligatures  are 


680 


GYNECOLOGY 


then  tied  within  the  abdominal  cavity.  The  success  of  the  operation  depends 
entirely  on  the  tying  of  the  hgatures,  the  object  of  which  is  to  create  two  short, 
small,  but  powerful  artificial  Hgamentous  attachments  between  the  abdominal 
wall  and  the  round  Hgaments.  In  order  to  accomplish  this  it  is  necessary  to 
injure  mechanically  the  epithelium  of  the  two  contiguous  peritoneal  surfaces, 
and  this  is  done  by  tying  the  hgatures  as  tightly  as  possible. 

Silk  is  used  because  with  no  other  form  of  Hgature  can  so  tight  a  knot  be  tied. 
It  is  used  braided  and  doubled  partly  because  it  will  not  break  in  tying  the 
knot  and  partly  because  it  will  not  cut  into  the  tissues  v/hen  powerful  tension 
is  put  upon  it.  It  is  somewhat  undesirable  to  bury  such  a  large  permanent 
ligature  in  the  abdominal  wall,  for  if  there  is  wound  sepsis  it  may  possibly  be- 
come infected  and  cause  a  persistent  sinus  until  it  is  removed.  This  does  happen 
once  in  awhile,  but  the  occurrence  is  so  rare  that  it  does  not  offset  the  advantages 
of  the  ligature.  , 

It  may  be  said  in  passing  that  a  far  more  powerful  and  lasting  ligament  can  be  created 
between  the  round  ligament  and  the  abdominal  than  between  the  uterine  wall  and  the  abdomi- 
nal wall.  Fixation  of  the  round  ligaments  is,  therefore,  more  reliable  than  fixation  of  the  uterus 
both  for  supporting  strength  and  for  the  avoidance  of  immobilizing  adhesions. 

The  Olshausen  operation  has  the  disadvantage  of  leaving  two  open  spaces 
between  the  ligaments  and  the  abdominal  wall  external  to  the  stitches  (Fig. 
333) .  "^  o  v)xvb  V  vQ,araexvts 


Fig.  .334. — Gilliam's  Operation. 

The  red  lines  indicate  the  course  of  the  round  ligaments,  which  are  drawn  up  through  all  the  layers 

and  fastened   on  the  outside  of  the  fascia. 


VARIOUS  FORMS  OF  THE  GILLIAM  OPERATION 

■    Gilliam's  Operation.— By  the  technic  of  the  original  Gilliam  operation  the 
perforating  clamp  is  carried  directly  through  the  fascia,  muscle,  and  peritoneum 


OPERATIONS    FOR' UTERINE    MALPOSITION 


681 


into  the  peritoneal  cavity  without  taking  the  obhque  route  through  the  internal 
ring.  The  round  ligament  is  drawn  directly  out  through  the  perforation  and 
fastened  to  the  outer  side  of  the  fascia  (Fig.  334).  This  has  the  advantage  over 
Simpson's  -operation  of  providing  a  direct  rather  than  an  indirect  pull  on  the 


M.9.  Gra\>e.2>T 


Fig.  3.35. — Simpson's  Operation  for  Retroversion. 
An  opening  has   been  made  in  the  fascia  and  a  specially  curved  clamp  passed  through  it  be- 
tween fascia  and  muscle.     The  point  of  the  curved  clamp  is  about  to  enter  the  internal  inguinal 
ring. 

uterus,  and,  therefore,  has  greater  supporting  power.  On  the  other  hand,  it 
leaves  two  openings  on  the  sides  through  which  the  intestines  may  prolapse,  and 
it  also  leaves  two  weak  points  in  the  fascia  through  which  the  loops  are  drawn. 
Simpson's  Operation.— Of  the  various  modifications  of  the  Gilliam  round 
ligament  operation,  that  of  Simpson  is,  in  the  opinion  of  the  author,  the  best. 


682 


GYNECOLOGY 


This  operation  has  the  advantage  of  securing  permanent  anterior  position  of  the 
uterus  without  danger  of  intestinal  comphcations.  It  has  excellent  supporting 
power.  There  is,  however,  danger  of  adhesions  forming  between  the  uterus  and 
the  abdominal  wall,  causing  an  occluding  diaphragm  across  the  pelvis,  with 
possible  subjective  symptoms  and  danger  of  dystocia.  This  latter  danger  which 
the  operation  shares  with  all  the  Gilliam  operations,  according  to  Simpson,  is 
obviated  if  his  technic  be  properly  followed. 

The  technical  steps  of  the  operation  are  as  follows:  Through    a   median 
incision  the  round  hgament  is  caught  in  pressure  forceps  about  1^  inches  from 


\k!5^&tCvV>(LS>- 


FiG.  3.36. — Simpson's  Operation  for  Retroversion. 
The  curved  clamp  has  been  passed  through  the  internal  ring,  beneath  the  peritoneum.     It  has 
pierced  the  peritoneum  and  is  in  the  act  of  grasping  the  round  ligament  preparatory  to  drawing  it 
back  through  the  internal  ring  (adapted  from  Simpson). 

the  uterus.  A  second  clamp  grasps  the  parietal  peritoneum  at  the  point  of  the 
internal  ring.  The  skin  is  retracted  from  the  wound  and  the  fascia  punctured 
about  1|  inches  to  the  side  of  the  lower  angle  of  the  incision.  A  specially 
curved  clamp  is  passed  through  the  puncture  and  obliquely  through  the 
rectus  muscle,  entering  the  space  between  the  leaves  of  the  broad  hgament 
through  the  internal  ring.  It  is  forced  along  in  the  subperitoneal  space 
until  it  reaches  the  clamp  first  placed  on  the  round  ligament  1^  inches  ffom 
the  uterus.  The  curved  clamp  is  forced  through  the  peritoneum  and  made  to 
grasp  the  round  hgament.     It  is  then  drawn  out,  bringing  the  loop  of  round 


OPERATIONS    FOR   UTERINE   MALPOSITION 


683 


ligament  with  it  through  the  channel  forced  by  its  entrance  into  the  abdominal 
cavity.  The  loop  of  the  round  ligament  is  fastened  beneath  the  rent  in  the 
fascia  by  a  linen  thread,  which  closes  the  rent  and  attaches  the  hgament  at  the 
same  time. 

The  procedure  is  repeated  on  the  other  side. 

In  choosing  the  point  of  the  ligament  which  is  to  be  drawn  through  the 
opening  it  is  important  not  to  take  it  too  close  to  the  uterus,  for  by  this  means 
the  uterus  is  drawn  too  snugly  against  the  anterior  abdominal  wall,  causing  the 
danger  of  occluding  adhesions  mentioned  above. 


Fig.  337. — -Simpson's  Operation  for  Retroversion. 
The  loop  of  round  ligament  is  brought  up  to  the  opening  in  the  fascia  where  it  is  being  anchored 
by  a  figure-of-8  stitch.     The  insert  shows  how  the  stitch  both  fastens  the  ligament  and  closes  the 
wound  in  the  fascia. 


In  order  to  perform  the  Simpson  operation  easily  it  is  of  very  great  moment 
that  the  perforating  clamp  have  a  proper  curve.  The  blades  are  somewhat 
longer  and  more  fully  curved  than  those  of  the  ordinary  half-length  clamp. 
Without  this  curve  the  passage  of  the  clamp  into  the  abdominal  cavity  is  some- 
times extremely  difficult. 

Mayo's  Modification  of  Gilliam's  Operation  (Internal  Alexander).— In  this 
operation  the  perforating  clamp  does  not  pierce  the  fascia,  but  passes  between 
the  fascia  and  the  outer  surface  of  the  rectus.  It  then  enters  the  internal  ring 
and  grasps  the  round  ligament  in  exactly  the  same  way  as  in  the  Simpson  opera- 
tion. After  the  ligaments  are  drawn  out  through  the  abdominal  wall  they 
are  crossed  over  in  front  of  the  recti  muscle  and  sewed  together  in  the  middle 


684, 


GYNECOLOGY 


c\\e~&  beneoJrtv 


Fig.  338. — Simpson's  Operation  for  Retroversion. 
The  round  ligament  has  been  drawn  through  the  internal  ring  and  attached  beneath  the  fascia 

(adapted  from  Simpson) . 


Nsll^cS 


Fig.  339. ■ — Simpson's  Oi'miiation  for  Retroveksion. 
The  operation  completed  and   viewed   by  imagination  from   inside   the  abdomen   (adapted  from 

Simpson) . 


OPERATIONS    FOR   UTERINE   MALPOSITION 


685 


line  (Fig.  340).  This  operation  has  no  advantages  over  the  Simpson  method, 
and  involves  the  objectionable  feature  of  joining  the  two  loops,  which  incurs 
the  danger  of  drawing  the  uterus  up  too  tightly,  with  consequent  adherence  to 
the  abdominal  wall. 

Kelly's  Modification  of  Gilliam's  Operation. — In  this  operation  the  per- 
forating clamp  passes  directly  through  the  rectus  muscle  and  peritoneum,  but 
not  through  the  fascia,  as  in  the  original  Gilliam's.     The  round  ligament  is 


Fig.  340. — Mayo's  Internal  Alexander. 

The  red  lines  indicate  the  course  of  the  round  ligaments.     They  are  drawn  through  the  inguinal  rings 

over  the  muscle  but  underneath  the  fascia,  the  loops  being  united  in  the  middle  line. 

drawn  straight  out,  giving  the  same  direct  pull  as  in  the  Gilliam  operation, 
and  is  joined  across  the  rectus  muscles  with  its  fellow  in  the  manner  used  by 
Mayo.  The  operation  gives  many  excellent  results,  but  has  the  same,  objections 
as  Mayo's  operation. 


BALDY'S  OPERATION  (Also  Called  the  Baldy-Webster  Operation) 

This  operation  is  useful  for  cases  of  simple  retroversion  and  for  retroversion 
with  moderate  prolapse,  where  no  great  supporting  power  is  required.  It  has 
the  advantage  of  securing  a  position  of  the  uterus  more  nearly  normal  than  does 
any  other  operation.  It  is  also  devoid  of  danger  from  childbirth  or  from  com- 
plications of  intestinal  obstruction.  ■ 

The  operation  is  performed  in  the  Trendelenburg, position.  The  broad  liga- 
ment of  the  right  side  is  pierced  by  a  half-length  clamp  "at" a  point  close  to  the 
uterus  and  directly  under  the  ovarian  ligament.  The  round  ligament  is  then 
grasped  by  thumb  forceps  at  a  point  about  one-third  of  the  length  of  the  ligiament 


686 


GYNECOLOGY 


from  the  uterine  end.  The  ligament  is  carried  by  means  of  thumb  forceps  into 
the  bite  of  the  perforating  clamp,  which  thus  seizes  the  ligament  and  draws  it 
through  the  perforated  opening  to  the  posterior  wall  of  the  uterus.  The  round 
ligament  of  the  left  side  is  then  drawn  through  an  opening  in  the  left  broad  liga- 
ment in  exactly  the  same  manner.  The  loops  of  the  two  round  hgaments  are 
next  sutured  together,  several  stitches  being  also  placed  to  unite  them  to  the 
posterior  wall  of  the  uterus.     Care  must  be  taken  to  attach  the  ligaments  at 


Fig.  341. — Baldy-Webster  Operation  for  Retroversion. 

An  opening  is  made  through  the  broad  Hgament  just  under  the  suspensory  ligament  of  the  ovary.     A 

half-length  forceps  passed  through  the  opening  grasps  the  round  ligament  and  draws  it  backward. 


just  the  right  level  on  the  back  of  the  uterus,  for  if  the  attachment  is  too  low 
the  uterus  may  become  retroflexed  over  the  ligaments,  and  if  the  attachment 
is  made  too  high  there,  is  danger  of  causing  an  anteflexion  of  the  uterus.  The 
perforation  of  the  broad  ligaments  and  the  suture  of  the  round  ligaments  must 
be  done  with  as  little  damage  to  the  peritoneum  as  possible,  for  otherwise  there 
is  liability  of  adhesions  of  the  ovaries,  a  complication  for  which  the  operation 
has  been  criticized. 


OPERATIONS    FOR   UTERINE   MALPOSITION 


687 


Fig.  342. — Baldy-Webstbr  Operation  for  Retroversion. 
The  round  ligament  of  the  right  side  is  being  drawn  through  the  opening  in  the  broad  ligament. 


Tig.  343. — ^Baldy-Webster  Operation  for  Retroversion. 
The  round  ligaments  of  the  two  sides  are  being  drawn  backward  through  the  openings  in  the  broad 

ligaments. 


688 


GYNECOLOGY 


Fig.  344. — Baldy-Webster  Operation  for  Retroversion. 
The  two  round  ligaments  are  attached  together  and  to  the  posterior  wall  of  the  uterus. 


ALEXANDER'S  OPERATION 

As  originally  performed  the  Alexander  operation  was  based  on  the  prin- 
ciple of  restoring,  the  retro  verted  uterus  to  a  forward  position  by  drawing  the 
round  ligaments  through  the  inguinal  rings,  where  they  were  anchored  by  su- 
tures, the  slack  of  the  ligaments  being  either  cut  or  redupHcated.  In  the  earher 
days  it  had  the  great  advantage  of  avoiding  the  necessity  of  opening  the  ab- 
dominal cavity,  which  at  that  time  constituted  a  dangerous  major  operation. 
There  were,  however,  serious  drawbacks  to  the  success  of  the  operation,  so  that 
when  asepsis  and  improved  surgery  made  exposure  of  the  peritoneum  com- 
paratively safe,  it  was  generally  discarded  in  favor  of  the  newer  procedures  for 
replacing  the  uterus.  Among  the  disadvantages  attending  the  operation  may 
be  mentioned,  first,  the  frequent  difficulty  of  finding  the  ligament.  It  was  usually 
sought  for  at  the  external  ring,  where  its  muscular  elements  blend  in  connective- 
tissue  fibers  running  down  into  the  labium  majus.  If  it  could  not  be  found 
here,  it  was  sought  in  the  inguinal  canal,  where  it  is  often  vague  and  difficult 
to  distinguish  from  the  surrounding  .parts.  Not  infrequently  wounds  were 
closed  without  either  ligament  being  discovered.  Another  difficulty  was  the 
frequency  with  which  the  ligaments  broke  when  tension  was  exerted  on  them. 
Still  another  disadvantage  was  the  inability  to  determine  whether  or  not  the 
retroverted  uterus-  was  adherent,  in  which  case  the  operation  was  valueless. 
Inguinal  hernias  and  wound  sepsis  were  common  complications.  In  the  study 
of  a  series  of  Alexander  operations  performed  in  the  old  way  the  author  found 
15  per  cent,  of  recurrences  in  cases  personally  examined. 


OPERATIONS    FOR   UTERINE   MALPOSITION 


689 


Though  the  operation  is  little  used  at  the  present  day  in  this  country,  it  has 
been  revived  abroad  under  the  name  of  the  Alexander-Adams  operation,  but 
with  an  improved  technic  which  does  away  with  many  of  the  former  objec- 
tionable features.  By  the  newer  method  the  peritoneal  cavity  is  opened  at  the 
inguinal  ring,  so  that  if  the  ligament  has  not  been  found  in  the  inguinal  canal  it 
can  be  traced  from  within  the  abdomen  outward.  By  securing  the  ligaments 
within  the  abdomen  they  may  be  drawn  out  without 'danger  of  rupturing  them. 
Moreover,  the  opening  of  the  abdomen  enables  the  surgeon  to  palpate  the  uterus, 
determine  its  position  after  traction  of  the  ligaments,  ascertain  the  presence  or 
absence  of  adhesions,  and  perform  minor  operations  on  the  appendages. 


^^•^S-- 


Fig.  345.^ — Alexander-Adams  Operation  for  Retroversion. 
The  round  ligaments  have  been  cut  and  freed,  and  are  being  drawn  upward  by  traction  clamps. 
The  peritoneum  has  been  opened  on  both  sides.     The  position  and  condition  of  the  uterus  is  being 
explored  by  the  two  forefingers. 


In  closing  the  wound  the  danger  of  postoperative  hernia  is  lessened  by 
treating  the  canal  in  the  manner  of  a  Bassini  operation  for  inguinal  hernia — i.  e., 
sewing  the  conjoined  tendon  to  Poupart's  ligament. 

The  technic  of  the  operation,  as  used  abroad  and  described  by  Doderlein- 
Kronig,  is  as  follows: 

A  3-inch  incision  is  made  parallel  to  Poupart's  ligament  as  in  the  operation 
for  inguinal  hernia.  The  incision  through  skin,  fat,  and  superficial  fascia  is 
carried  down  to  the  white  glistening  fascia  of  the  external  oblique  muscle.  The 
external  inguinal  ring  is  exposed,  easily  recognizable  by  the  divergence  of  the 
fascial  fibers  and  by  its  relation  to  the  pubic  spine.     The  fibers  of  the  external 

44 


690 


GYNECOLOGY 


oblique  are  split  above  the  external  ring  in  a  direction  parallel  with  Poupart's 
ligament.  In  ordinary  cases  the  round  ligament  may  easily  be  seen  lying  in  the 
bed  of  the  inguinal  canal,  but  if  it  cannot  be  distinctly  defined,  an  opening  is 
made  through  the  peritoneum  at  the  internal  ring,  when  the  ligament  can  be 
followed  from  within  outward.  The  ligament  is  drawn  up  with  two  clamps  at 
its  distal  end  and  severed  between  the  clamps.  It  is  then  freed  from  its  bed 
and  drawn  firmly  outward  until  the  cone-shaped  reflection  of  the  peritoneum 
surrounding  the  proximal  end  of  the  hgament  is  brought  into  view. 


JV'poueucusiS-      -J'Xi^ 


\ 


V4A?Gra{tfcr"l\-yC 


Fig.  346. — Alexandee-Adams  Operatio^t  for  Retroversion. 
Opening  the  peritoneum.     By  traction  on  the  round  ligament  the  peritoneum  is  drawn  up  in  a  funnel- 
shaped  fold  (after  Doderlein-Kronig) . 


The  peritoneal  reflection  is  now  opened  (Fig.  346),  and  the  operation  up  to 
this  point  repeated  on  the  other  side. 

The  forefingers  of  the  two  hands  are  now  introduced  into  the  peritoneal 
cavity,  as  in  Fig.  345,  and  the  pelvis  explored.  By  this  maneuver  the  position 
of  the  uterus  is  controlled.  When  the  desired  position  is  attained  the  ligaments 
are  sewed  to  the  under  side  of  the  outer  flap  of  fascia  and  the  redundant  portion 
cut  off.      In  order  to  guard  against  possible  postoperative  hernia  the  edge  of  the 


OPERATIONS    FOR    UTERINE   MALPOSITION 


691 


Fig.  347. — Alexander-Adams  Operation  for  Retroversion. 
Closure  of  peritoneal  opening  and  suture  of  the  round  ligament  to  tHe  under  side  of  the  fascia  (after 

Doderlein-Kronig) . 


conjoined  tendon  is  attached  by  a  few  stitches  to  Poupart's  ligament, 
wound  is  closed  by  overlapping  the  fascia  layer. 


The 


Operations  for  Anteflexion 
pessaries  for  anteflexion  of  the  cervix 

'As  has  been  stated  (see  page  466),  the  use  of  intra-uterine  pessaries  is  un- 
surgical  in  principle,  and  may  be  followed  by  inflammatory  processes  in  the 
tubes,  of  which  we  have  observed  two  instances.  Nevertheless,  even  with  this 
risk  the  procedure  is  regarded  as  justifiable  and  is  very  widely  employed.  If 
apphed  to  the  proper  cases  the  results  gained  by  pessaries,  both  for  dysmenor- 
rhea and  sterility,  are  comparatively  good. 

Numerous  forms  of  pessaries  are  in  use,  some  of  which  require  sutures  in 
the  cervix  to  keep  them  in  place,  others  being  self -retaining  in  principle.  We 
greatly  prefer  the  latter  type,  as  the  sutures  used  for  sewing  in  the  instrument 
inevitably  cause  a  greater  or  less  inflammatory  reaction  in  the  cervix  that  some- 
times continues  in  the  form  of  a  chronic  cervicitis  or  endocervicits  after  the 
removal  of  the  pessary. 

■      In  using  the  other  type  of  intra-uterine  pessary   it  is  important  to  insert 
also  a  vaginal  pessary,  which  not  only  prevents  the  intra-uterine  instrument 


GYNECOLOGY 


Fig.  348. — Uterine    Stem-pessary    Contain- 
ing Groove  for  Drainage. 


CJ 


G^ 


Fig.  350. — Applicator  Used   for   Intro- 
Fig.  349. — Chamberlain's       Intra-uterine       ducing  the  Uterine  Stem-pessart  Pictured 
'  Stem-pessart.  in  Fig.  349. 


OPERATIONS    FOE    UTERINE   MALPOSITION  693 

from  slipping  out,  but  also  maintains  a  good  position  of  the  uterus,  which  in 
most  cases  of  anteflexion  is  retrocessed. 

The  forms  of  pessary  recommended  by  the  author  are  shown  in  Figs.  348 
and  349-  In  the  first  one  there  is  a  groove  that  provides  for  proper  drainage. 
The  second  pessary  shown  is  an  excellent  one,  ingeniously  devised  by  Chamber- 
lain.    It  is  conveniently  introduced  by  the  apphcator  shown  in  Fig.  350. 

In  applying  an  intra-uterine  pessary  the  patient  should  be  under  complete 
anesthesia  in  order  that  the  cervix  may  be  thoroughly  dilated.  It  is  usually 
not  necessary  to  curet  the  endometrium.  In  fact,  it  is  desirable  to  leave  this 
intact,  for  the  dangers  of  sepsis  are  increased  if  a  foreign  body  in  the  form  of  a 
pessary  is  left  in  contact  with  an  abraded  mucous  surface. 

The  pessary  is  left  in  from  six  weeks  to  two  or  three  months.  It  must  be 
very  carefully  watched  by  the  attending  physician,  and  should  be  removed  at 
once  if  undue  leukorrheal  discharge  or  pelvic  pain  appear.  The  self-retaining 
pessaries  can  be  extracted  without  trouble.  Those,  however,  that  have  been 
sewed  into  the  cervix  sometimes  cause  considerable  embarrassment  in  their 
removal. 

OPERATIONS  ON  THE  CERVIX  FOR  ANTEFLEXION 

Several  operations  on  the  cervix  for  straightening  the  uterine  canal  have 
been  devised.  Baker's  operation  consists  in  removing  a  transverse  wedge  from 
the  posterior  wall  of  the  cervix.  The  operation  is  a  difficult  one,  and  can  best 
be  performed  with  the  patient  in  the  Sims  position.  An  oval  incision  is  made, 
the  width  of  which  includes  most  of  the  posterior  vaginal  portion  of  the  cervix, 
the  ends  of  the  oval  being  carried  around  to  the  sides  of  the  cervix.  In  excising 
the  wedge  it  is  usually  necessary  to  enter  the  cervical  canal,  which,  however, 
does  no  harm.  Severe  bleeding  may  be  encountered  as  the  wound  reaches  to 
the  sides  of  the  cervix.  The  bleeding  vessels  should  be  tied  with  hgatures 
sewed  into  the  cervical  tissue.  The  wound  is  closed  with  interrupted  catgut 
stitches.  This  operation,  if  properly  done,  straightens  out  the  angulation  of 
the  cervix  and  does  not  mutilate  it.  Symptomatic  results  are,  however,  only 
moderately  satisfactory. 

Pozzi's  operation  consists  in  creating  an  artificial  bilateral  laceration  of  the 
cervix. 

With  the  patient  in  the  perineal  position,  the  anterior  and  posterior  hps  of  the 
cervix  are  incised  deeply  to  the  level  of  the  internal  os,  in  the  form  of  a  bilateral 
laceration.  Wedge-shaped  pieces  of  cervical  tissue  are  removed  from  the  two 
wounds  thus  made  in  order  to  allow  for  the  approximation  of  the  vaginal  and 
cervical  mucous  membranes.  The  wounds  are  closed  with  interrupted  catgut 
sutures.  This  operation  is  a  mutilating  one,  and  is  apt  to  be  followed  by  the 
same  compfications  that  result  from  laceration  by  childbirth — i.  e.,  ectropion, 
€ndocervicitis,  and  cervicitis.  Our  short  experience  with  the  operation  has  been 
unsatisfactory,  and  we  have  discarded  it  in  our  chnic. 


694 


GYNECOLOGY 


Dudley's  Operation.- — Another  principle,  used  for  many  years  for  ante- 
flexion, is  that  of  posterior  discission  of  the  cervix,  including  the  internal  os. 
This  does  away  with  the  lower  leg  of  the  angle  and  theoretically  relieves  obstruc- 
tion. The  technic  devised  by  Dudley  is  the  best  one  to  employ  in  performing 
this  operation. 

With  the  patient  either  in  the  Sims  or  perineal  position,  the  cervix  is  first 
thoroughly  dilated.  The  posterior  wall  of  the  cervix  is  then  divided  exactly 
in  the  median  line  back  as  far  as  the  junction  of  cervix  and  vagina. 

The  next  step  is  to  sever  the  constriction  at  the  internal  os.  This  is  done 
with  a  narrow  scalpel,  which,  under  guidance  of  the  finger,  cuts  the  fibers  of  the 
internal  os  until  the  opening  is  sufficiently  wide  to  admit  the  finger  into  the 


Vv(^@^ 


Fig.  351. — Dudley's    Operation  fob  Ante- 
flexion. 
Removal  of  wedges  from  the  sides  of  the  incision 
and  placing  of  the  approximating  stitch. 


Fig.  352. — Dudley's    Operation   for   Ante- 
flexion. 
Closure  of  the  wound. 


uterine  canal.  Care  must  be  exercised  in  performing  this  part  of  the  operation 
not  to  enter  the  peritoneal  cavity  in  the  pouch  of  Douglas,  an  accident  that, 
however,  does  no  special  harm. 

The  next  maneuver  is  to  approximate  the  ends  of  the  wound  at  the  external 
OS  to  the  upper  angle  of  the  wound.  In  order  to  accomplish  this  without  tension, 
wedge-shaped  pieces  of  tissue  are  removed  from  the  middle  portion  of  each  side 
of  the  wound,  as  shown  in  the  drawing  (Fig.  351).  A  stitch  is  then  introduced 
in  the  manner  shown  in  Fig.  351,  which  when  taut  draws  the  posterior  part  of 
the  external  os  up  to  the  angle  of  the  wound  at  the  internal  os.  Stitches  are 
placed  in  the  lateral  parts  of  the  wound  to  control  hemorrhage  and  secure  good 
coaptation  of  the  wound  edges. 


OPERATIONS    FOR    UTERINE    MALPOSITION 


695 


This  operation  is  frequently  followed  bj'  good  results  as  regards  the  rehef  of 
dysmenorrhea  and  the  cure  of  sterihty.  It  is,  however,  mutilating  to  the 
cervix,  and  is  often  foUowed  by  ectropion  and  endocervicitis  with  annoying 
leukorrheal  discharge.  We  have  on  a  number  of  occasions  been  obhged  to  per- 
form a  tracheoplasty  to  reheve  the  symptoms  caused  by  the  operation. 

ABDOMINAL  OPERATION  FOR  ANTEFLEXION  (AUTHOR'S  METHOD) 

As  has  been  pointed  out  on  page  482,  the  only  way  permanently  to  straighten 
out  an  anteflexed  uterus  without  mutilating  it  is  by  means  of  suspending  it 


\i.^.GTa««3--i9'3 


/ 


Fig.  353. — Positiox  of  Uterus  ix  Axteflexion. 

The  uterus  is  sharply  bent  on  itself  and  the  whole  organ  sags  back  toward  the  sacruna  in  the  position 

of  retrocession.     The  cenix  is  disproportionately  long. 


from  above.  We  have  employed  this  principle  for  several  years,  and  have 
secured  much  better  results,  especially  for  dysmenorrhea,  than  by  any  other 
method. 

The  mechanical  principle  involved  is  ihustrated  in  Figs.  353  and  354,  in 
which  it  is  seen  that  the  anteflexed  retrocessed  uterus  may  be  brought  into  a 
practically  normal  position  by  suspension  from  the  abdominal  wall. 

Several  operations  maj^  be  used  for  the  reduction  of  anteflexion — e.  g.,  the 


696 


GYNECOLOGY 


Alexander- Adams,     Gilliam's,     Mayo's,     Simpson's,     and    Olshausen's.      The 
Baldy- Webster  and  Coffey  operations  are  inapplicable  to  this  condition. 


Ni.^.<aTcvx\es.vS\^r^ 


Fig.  354. — Axteflexion   of  the   Uterus   Reduced    by   Olshausen's   Operation     (Author's 

Method). 

By  drawing  the  uterus  up  to  the  abdominal  wall  by  means  of  the  round  ligaments,  the  anteflexion 
is  completely  and  permanently  straightened  out  and  the  whole  organ  is  lifted  out  of  the  position  of 
retrocession.  By  employing  the  Olshausen  method  of  suspension  the  necessary  position  of  the  uterus 
can  be  accurately  gaged. 

We  are  accustomed  to  use  the  Olshausen  operation,  as  it  is  possible  by  this 
method  to  secure  exactly  the  required  correction  of  the  anteflexion  and  the 
most  favorable  position  for  the  uterus. 


Operations  for  Prolapse  and  Procidentia 


PROCIDENTIA 

The  technic  usually  employed  by  the  author  for  advanced  cases  of  procidentia 
is  as  follows: 

(1)  High  amputation  of  the  cervix  is  performed  by  the  Hegar  method  de- 
scribed on  page  599. 

(2)  An  extensive  anterior  colpoplasty  is  then  done  by  the  author's  method 
described  on  page  608. 


OPERATIONS    FOR    TTERINE    ^L\LPOSITION 


697 


(3)  Perineoplasty  is  performed  according  to  the  technic  described  for  the 
modified  Emmet  operation  on  page  625. 

(4)  The  patient  is  then  placed  in  the  Trendelenburg  position,  the  abdomen 
opened  by  a  small  incision,  and  the  uterus  and  adnexa  removed  by  the  technic 
described  for  supravaginal  hysterectomy  (see  page  713). 

(5)  When  the  uterus  has  been  amputated,  the  cervix  closed,  and  the  uterine 
vessels  tied,  two  sutures  of  No.  7  braided  silk  are  passed  deeply,  one  on  each 
side  of  the  cervix  (Fig.  355).  the  ends  being  left  long  and  the  needles  attached. 
These  sutures  are  to  serve  later  to  attach  the  cer\ical  stump  to  the  anterior 
abdominal  wall. 


Fig.  355. — Operation'  for  Procidentia  (Author's  Method). 
The  uterine  body  has  been  amputated  and  the  broad  ligaments  sewed  to  the  cen-ical  stump. 
Two  strong  silk  sutures  have  been  introduced  through  the  firm  tissue  of  the  cer^-ieal  stump,  which  are 
to  be  used  to  attach  the  stump  to  the  anterior  abdominal  wall.  The  bladder  flap  is  being  drawn  up 
and  is  to  be  attached  to  the  posterior  wall  of  the  vagina,  so  that  it  entirely  covers  the  cervical  stimip 
and  the  attached  stumps  of  the  broad  ligaments. 

The  broad  hgaments  are  then  sewed  to  the  stump  of  the  cer^dx  in  the  same 
manner  as  in  supravaginal  hj^sterectomy  (Fig.  381). 

The  next  step  resembles  the  turning  over  of  the  uterovesical  flap  of  perito- 
neum (Fig.  382),  except  that  in  this  case  the  bladder  is  dissected  away  from 
the  vagina  for  a  considerable  distance.  The  peritoneal  fold  is  then  carried  far 
over  the  stump  of  the  cervix  and  attached  low  down  toward  the  pouch  of  Douglas 
to  the  posterior  wall  of  the  vagina.  In  this  way  the  cervix  and  broad  hgament 
are,  in  a  sense,  interposed  under  the  bladder. 


698 


GYNECOLOGY 


When  this  step  has  been  completed,  the  two  silk  suspensory  sutures  are 
passed  into  the  abdominal  wall,  one  on  each  side  of  the  median  incision.  Each 
suture  includes  the  peritoneum,  muscle,  and  fascia.  The  knots  are  tied  on  the 
inside  as  tightly  as  possible,  in  order  to  insure  a  strong  artificial  suspensory 
ligament.  The  portion  of  the  bladder  lying  between  these  two  sutures  is  not 
compressed  and  suffers  no  later  inconvenience.  By  this  operation  the  support 
of  the  bladder  and  vagina  has  a  double  defense.     The  primary  defense  consists 


"Reflection  """"l* 


IS>\a^6 


^v 


Via 


L^ttWJl„ 


Vl.^.6««.wa,9. 


Fig.  356. — Operation  for  Procidentia  (Author's  Method). 
Sagittal  section  showing  completed  operation.  The  cervix  and  body  of  the  uterus  have  been 
amputated,  leaving  only  a  disk  of  uterine  tissue.  The  bladder  has  been  drawn  up  over  this  disk  and 
attached  by  its  flap  to  the  posterior  wall  of  the  vagina.  The  whole  mass,  including  the  disk,  the  at- 
tached broad  ligament,  and  the  upper  wall  of  the  bladder,  has  been  fixed  to  the  anterior  abdominal 
wall.  The  manner  in  which  the  cystocele  is  reduced  by  this  maneuver  is  shown  in  the  drawing.  The 
auxiliary  operation  on  the  anterior  and  posterior  walls  of  the  vagina  is  not  represented. 


of  the  two  artificial  hgaments  made  between  the  stump  -of  the  cervix  and  the 
anterior  abdominal  wall.  The  secondary  defense  consists  of  the  broad  hga- 
ments brought  together  by  their  attachment  to  the  cervical  stump,  on  which  a 
portion  of  the  bladder  rests  as  on  a  shelf. 

The  results  of  this  operation  are  excellent,  there  being  httle  danger  of 
recurring  prolapse  of  the  cervix  or  anterior  wall  of  the  vagina.  Recurrence  of 
the  rectocele  has  in  a  few  instances  been  seen  requiring  re-operation  on  the 


OPERATIONS    FOR   UTERINE   MALPOSITION 


699 


perineum.  The  recurrence  of  rectocele  may  be  avoided  by  applying  several 
stitches  in  Douglas'  fossa  in  the  manner  used  in  the  Moschowitz  operation 
for  rectal  proJapse  (g.  v.). 

If  the  patient  is  desirous  of  having  children,  the  operation  for  moderate  pro- 
cidentia may  be  done  satisfactorily  without  removing  the  uterus.  The  initial 
steps  of  the  operation  are  the  same  as  in  that  already  described — i.  e.,  high 
amputation  of  the  cervix,  anterior  colpoplasty,  and  perineoplasty.  Instead  of 
performing  a  supra-vaginal  hysterectomy  with  abdominal  fixation  of  the  cervical 
stump,  it  is  possible  to  secure  an  excellent-  result  by  suspending  the  uterus  by 


Fig.  357. — Operation  for  Procidentia  (Author's  Method). 
This  is  an  imaginary  view  of  the  completed  operation  seen  from  within  the  abdominal  cavity. 
The  bladder  flap  has  been  drawn  over  and  attached  by  one-  catgut  suture  behind  the  cervix.  If  there 
is  great  relaxation  of  the  bladder  the  flap  may  be  attached  much  deeper  in  the  culdesac  than  is  shown 
in  the  drawing.  The  two  silk  sutures  shown  in  Fig.  355  have  been  introduced  into  the  abdominal 
wall  through  peritoneum,  muscle,  and  fascia  and  tied  on  the  inside,  as  in  the  Olshausen  operation 
(Fig.  332  The  abdominal  wound  has  been  closed.  If  by  an  unusual  chance  this  fixation  attach- 
ment should  give  way,  it  may  be.  seen  that  the  broad  ligaments  form  an  efficient  ' '  secondary  defense ' ' 
to  prevent  prolapse  of  the  cer\dx  and  the  vaginal  vault. 

the  Olshausen  method  sufficiently  high  up  on  the  abdominal  wall  to  reduce  the 
prolapse.  The  dangers  as  to  childbirth,  if  the  patient  becomes  pregnant,  are 
no  greater  than  after  any  of  the  suspensory  round  figament  operations. 


THE  WATKINS  INTERPOSITION  OPERATION  FOR  PROLAPSE  AND   PROCIDENTIA 

The  principle  of  the  Watkins  operation  is  based  on  a  separation  of  the 
bladder  from  the  anterior  wall  of  the  uterus  and  transposing  its  attachment  to 
the  posterior  wall,  so  that  the  uterus  is  left  in  a  position  to  support  the  entire 
bladder.  Watkins  performed  his  first  operation  in  1898.  Several  modifica- 
tions, notably  that  of  Wertheim,  have  appeared  since. 


700 


GYNECOLOGY 


Fig.  358.— Watkins'  Opebatiox  for  Procidentia. 
Separating  the  vaginal  wall  from  the  bladder  by  blunt  dissection  wdth  scissors. 


OPERATIONS    FOR   UTERINE   MALPOSITION 


701 


Fig.  359.— Watkins'  Operation  for  Procidentia. 
Separating  the  bladder  from  the  cervix  by  blunt  dissection  ^-ith  scissors. 


702 


GYNECOLOGY 


The  technic  of  the  Watkins  operation  is  as  follows : 

The  anterior  hp  of  the  cervix  is  grasped  with  traction  forceps  and  drawn 
forcibly  down  to  or  out  of  the  introitus.  A  transverse  incision  is  made  at  the 
junction  of  the  bladder  and  the  portio.  The  ends  of  the  incision  are  grasped 
with  pressure-forceps  and  held  taut.  The  end  of  a  pair  of  scissors,  closed,  is 
then  inserted  in  the  wound  and  forced  upward  toward  the  meatus,  in  the  plane 


Crown 
"'-Suture 


tf.SxrcvociS;. 


Fig.  360. — Watkins'  Operation  for  Procidentia. 
The  fundus  has  been  delivered  beneath  the  bladder.     The  crown  stitch  has  been  applied. 

of  cleavage  between  the  bladder  and  anterior  vaginal  wall  (Fig.  358).  When 
the  level  of  the  urethra  is  reached  the  scissors  are  opened  and  withdrawn,  thus 
creating  an  area  of  separation  of  bladder  and  vagina,  the  amount  of  which 
varies  according  to  the  size  of  the  cystocele  and  the  amount  of  adherence  be- 
tween the  two  layers  of  tissue.  In  performing  this  part  of  the  operation  there 
is  considerable  danger  of  injuring  the  bladder.     This  must  be  guarded  against 


OPERATIONS    FOR    UTERINE   MALPOSITION 


703 


by  gentle  manipulation  of  the  tissues.  When  the  bladder  and  vagina  have  been 
separated,  the  anterior  vaginal  wall  is  incised  along  the  median  line  and  the 
edges  of  the  flaps  caught  with  pressure  forceps.  The  flaps  are  then  stripped 
further  back  by  blunt  dissection.  The  amount  of  stripping  of  these  flaps  should 
be  only  enough  to  cover  the  anterior  wall  of  the  uterus  in  its  new  position.  In 
case  of  an  extensive  cystocele,  where  it  is  desirable  later  to  cut  away  redundant 
parts  of  the  wall,  the  stripping  of  the  flaps  is,  of  course,  carried  further. 


~~^^,<=>xrcv.\iCS> 


Fig.  36L — Watkixs'  Operatiox  for  Procidentia. 
The  crown  suture. 


The  next  step  is  to  separate  the  bladder  from  the  cervix.  This  is  done  by 
inserting  the  scissors  in  the  line  of  cleavage  for  a  short  distance  and  then  opening 
them  (Fig.  359).  This  process  is  repeated  carefully,  and  with  the  points  of  the 
scissors  pressing  against  the  cervix  until  the  movable  plica  of  the  peritoneal 
reflection  from  bladder  to  uterus  is  reached.  The  separation  of  the  bladder  is 
not  always  easy.     In  cases  of  difliculty  Watkins  recommends  separating  the 


704 


GYNECOLOGY 


lateral  portions  first,  as  the  adherence  of  the  tissues  is  less  there  than  along  the 
median  line. 

Where  the  peritoneal  fold  comes  into  view  it  is  picked  up  with  tissue  forceps 
and  cut.  The  opening  thus  made  is  enlarged  either  by  cutting  or  by  forcing 
it  open  with  the  finger. 

The  next  step  is  the  delivery  of  the  uterus  through  the  wound.  A  narrow 
retractor  is  inserted,  drawing  the  bladder  well  up  to  the  symphysis.  The  ante- 
rior wall  of  the  uterus  is  first  seized  with  traction  forceps  and  drawn  downward 
and  forward,  carrying  the  cervix  up  and  back.     By  this  maneuver  one  can  grasp 


N\L  '^.&-.  (x^tcx  ViatKvns 


Fig.  362. — Watkins'  Operation  for  Procidentia. 
Diagram  showing  position  of  organs  when  the  operation  is  finished. 


the  fundus  of  the  uterus  with  traction  forceps  and  deliver  it  through  the  wound. 
Watkins  cautions  against  the  attempt  of  dehvering  the  uterus  by  the  anterior 
wall  because  its  diameters  are  greater  than  those  of  the  fundus. 

With  the  uterus  held  forward  out  of  the  wound,  sutures  are  now  placed  as 
in  Fig.  360,  connecting  the  upper  end  of  the  vaginal  wound  with  the  fundus  of 
the  uterus.  In  attaching  these  sutures  one  must  keep  in  mind  that  it  is  im- 
portant to  superimpose  the  entire  bladder  on  the  uterus,  but  not  to  fix  the  uterus 
so  firmly  against  the  urethra  as  to  interfere  with  urination. 

The  vaginal  wound  is  now  closed  over  the  anterior  surface  of  the  uterus  by  a 


OPERATIONS    FOR   UTERINE   MALPOSITION 


705 


continuous  catgut  suture,  which  occasionally  catches  the  peritoneum  of  the 
uterus.    The  transverse  incision  may  be  sewed  up  transversely  or  longitudinally. 

If  the  operation  is  done  during  the  reproductive  period,  the  uterine  ends  of 
the  tubes  should  be  ligated  and  severed,  and  peritoneum  sewed  over  the  exposed 
surfaces  in  order  to  prevent  possible  impregnation. 

If  the  cervix  is  much  elongated  and  hypertrophied,  the  operation  should  be 
preceded  by  amputation  of  the  cervix. 

In  all  cases  a  careful  perineoplasty  should  be  performed. 


Fig.  363. — Watkins'  OpERATioisr  for  Procidentia. 
Closure  of  wound. 


Wertheim  described  an  operation  in  1899  similar  to  that  of  Watkins  and 
based  on  the  same  mechanical  principles.  In  the  Wertheim  operation  the 
bladder  is  stitched  to  the  posterior  wall  of  the  uterus  at  the  level  of  the  internal 
OS  (Fig.  364).  In  closing  the  vaginal  wound  a  portion  of  anterior  wall  of  the, 
uterus  is  left  exposed  in  the  vagina  (Fig.  365).  From  a  surgical  standpoint, 
Watkins'  technic  is  obviously  superior,  .• 

45 


706 


GYNECOLOGY 


GOFFE'S  OPERATION  FOR  PROLAPSE 

A  vaginal  operation  for  moderate  prolapse  and  cystocele  somewhat  similar 
in  mechanical  principle  to  that  of  Watkins,  though  not  as  radical,  has  been 
devised  by  Goffe.  The  uterovesical  pouch  is  opened  as  in  the  Watkins  operation, 
or  as  described  for  Anterior  Colpotomy  (see  page  676). 


"titb  anb  tut 


[nM^.Gt^ 


Fig.  364. — Wertheim's  Oper.'\.tiox  for  Prolapse  and  Procidentia. 
Showing  how  the  edge  of  the  peritoneal  reflection  is  stitched  to  the  posterior  wall  of  the  uterus 

(adapted  from  Doderlein-Kronig) . 

The  uterus  is  then  delivered,  and  a  shortening  of  the  round  ligaments  by 
reduphcation  performed  through  the  vaginal  opening.  The  principle  involved 
in  this  operation  is  to  shift  the  bladder  around  on  the  uterus  so  as  to  form  a  new 
attachment  not  only  in  the  median  line,  but  also  at  the  two  cornua  of  the 
bladder. 

A  description  of  the  steps  of  the  operation  from  this  point  is  quoted  from 

Goffe: 


OPERATIONS    FOR   UTERINE   MALPOSITION 


707 


"The  object  of  the  next  procedure  is  to  carry  up  into  the  pelvis  and  to  fix 
the  firm  immovable  base  of  the  bladder.  To  accomphsh  this  a  point  is  se- 
lected in  the  middle  of  the  base  of  the  bladder  wall  which,  when  carried  up  to 
the  torn  edge  of  the  peritoneum  on  the  anterior  face  of  the  uterus,  middle  point, 
will  take  up  all  the  slack  in  the  base  of  the  bladder,  making  a  comparatively 
straight  line  from  the  urethra  to  the  uterus.  Through  this  point  a  suture  is 
passed  and  carried  also  through  the  selected  point  on  the  anterior  face  of  the 


— V)ttruS 


V.T^^^n 


Fig.  366 — Wertheim's  Operation  for  Prolapse  and  Procidentia. 

In  this  operation  the  peritoneum  of  a  portion  of  the  fundus  of  the  uterus  is  left  exposed  in  the  vagina. 

Compare  this  with  Fig.  363,  wliich  shows  the  Watkins  method  of  vaginal  closure. 


uterus,  catching  up  in  its  course  the  corresponding  torn  edge  of  the  peritoneum 
on  the  bladder.  This  suture  is  left  long  and  is  not  tied  until  all  the  sutures  are 
passed.  Two  points  are  then  selected  in  the  base  of  the  bladder  on  either  side 
on  a  transverse  line  with  the  first  selected  point  and  equally  distant.  These 
two  points  indicate  the  cornua  of  the  bladder.  Through  them  similar  sutures 
are  passed  and  carried  through  the  round  ligaments  or  points  on  the  torn-off 
edges  of  peritoneum  on  the  surface  of  either  broad  ligament  sufficiently  distant 
from  the  middle  point  to  take  up  all  the  slack  in  the  base  of  the  bladder,  from 


708 


GYNECOLOGY 


side  to  side;  these  sutures  are  also  left  long.  The  three  sutures  are  then  tied 
successively,  beginning  with  the  middle  one.  The  effect  of  this  is  to  stretch  the 
base  of  the  bladder  taut  and  smooth  in  every  direction.  This  restores  the 
support  of  the  bladder  which  is  derived  from  the  uterus.  In  addition  to  this, 
it  is  necessary  to  overcome  the  condition  of  hernia,  and  secure  to  the  bladder  the 
support  which  it  receives  from  the  fascia  lata.     This  is  accomphshed  in  the 


Fig.  366. — The  Matos'  Vaginal  Operation  for  Procidentia. 
The  broad  ligaments  are  being  united  by  a  running  mattress  suture  (adapted  from  the  Mayos). 


following  manner:  The  fascia  along  the  middle  hne  of  the  vaginal  incision  and 
the  mucous  membrane  as  well  are  then  trimmed  off  at  either  side  sufficiently 
to  remove  the  overstretched  and  ruptured  part  of  the  fascia  and  secure  for 
support  the  strong  uninjured  portion  of  the  fascia  lata.  The  freshened  edges  of 
the  fascia  lata  and  vaginal  mucous  membrane  are  then  stitched  together  through- 
out the  whole  length  of  the  vagina,  thus  bringing  it  up  snugly  against  the  base 


OPERATIONS    FOR    UTERINE   MALPOSITION 


709 


of  the  bladder.     The  uterine  end  of  the  vaginal  incision  is  then  stitched  to  the 
uterus  directly  under  the  attachment  of  the  bladder." 

For  complete  procidentia  Goffe  applies  the  same  principle  in  a  more  radical 
way:  The  uterus  is  first  removed  by  vaginal  hysterectomy  (see  page  728). 
The  two  broad  ligaments  are  then  stitched  together  across  the  pelvis.  Upon 
this  newly  constructed  plane  the  bladder  wall  is  spread  out  and  stitched,  in 
practically  the  same  manner  used  in  the  prolapse  operation,  in  which  the  bladder 


_,i.V^     Dx-ocvbLup 


Fig.  367. — The  Mayos'  Operation  for  Procidentia. 

The  broad  ligaments  have  been  united  in  the  middle  line.     The  vaginal  mucous  membrane  is  being 

approximated  by  a  running  stitch  (adapted  from  the  Mayos). 

was  attached  to  the  anterior  uterine  wall.     To  this  plane  is  also  attached  the 
upper  end  of  the  vagina. 


THE   MAYOS'  OPERATION  FOR  PROCIDENTIA 

An  operation  for  procidentia  combining  the  principles  of  the  Watkins  and 
Goffe  operations  is  that  devised  by  the  Mayos. 

A  vaginal  hysterectomy  is  performed  as  described  on  page  728,  except 
that  clamps  are  used  on  the  broad  hgaments  instead  of  ligatures.  The  edges 
of  the  broad  ligaments  are  then  approximated  laterally,  and  a  running  mattress 
suture  of  chromicized  catgut  passed  through  both  ligaments,  along  a  line  suffi- 


710 


GYNECOLOGY 


ciently  far  back  of  the  clamps  so  that  when  drawn  taut  the  broad  hgaments  are 
tightened  (Fig.  366).  This  mattress  stitch  runs  at  a  distance  of  1  to  1|  inches 
from  the  edges  of  the  ligaments,  and  is  designed  also  to  secure  the  vessels  without 
possibility  of  shpping. 

The  upper  border  of  the  united  broad  ligaments  is  then  stitched  to  the 
vaginal  wall  at  the  level  of  the  upper  angle  of  the  vaginal  wound.  This  compels 
the  bladder  to  rest  on  the  broad  ligaments  as  on  a  kind  of  shelf.     The  loose 


Fig.  368. — Spinelli'.s  Oplr\tiox  for  Inversion. 
The  initial  incision. 

edges  of  the  broad  ligament  are  now  stitched  smoothly  together,  and  the  vaginal 
flaps  closed  by  a  running  suture  (Fig.,  367). 


CONSERVATIVE  OPERATION  FOR  INVERSION  OF  THE  UTERUS 

The  technic  of  the  operation  devised  by  Kiistner  for  inversion  is  as  follows: 
A  wide  transverse  incision  is  made  opening  the  pouch  of  Douglas.     The 
forefinger  of  the  left  hand  is  introduced  through  this  incision  into  the  cup- 
shaped  depression  caused  by  the  inversion  of  the  fundus.     If  the  uterus  can  be 


OPERATIONS    FOR    UTERINE    MALPOSITION 


711 


brought  outside  of  the  vulva,  the  inverted  fundus  will  appear  uppermost,  the 
posterior  aspect  of  the  uterus  and  cervix  being  toward  the  operator.  A  longi- 
tudinal incision  is  then  made  exactly  in  the  middle  line,  dividing  the  posterior 
wall  of  the  cervix  and  a  part  of  the  posterior  wall  of  the  fundus.  With  the  fore- 
finger in  the  cup-shaped  depression  on  the  abdominal  side,  and  the  thumb  on  the 
fundus  of  the  exposed  side,  the  uterus  can  now  be  reinverted  to  its  original  con- 
dition.    The  reinverted  fundus  is  retroflexed  and  drawn  out  through  the  poste- 


Fig.  369. — Spinelli's  OpER.iTioN  for  Ix\'ersion. 
The  anterior  wall  of  the  uterus  has  been  opened  preparatory  to  reinverting  it. 

rior  colpotomy  opening,  and  the  wound  of  the  posterior  wall  and  cer\dx  closed 
wdth  deep  catgut  sutures.     The  posterior  colpotomy  wound  is  sewed. 

This   operation  has   been  modified  by  other  operators,    who   recommend 
making  an  anterior  vaginal  incision. 


SPINELLI'S  OPERATION  FOR  INVERSION  OF  THE  UTERUS 

Spinelli's  modification  of  Kiistner's  principle  of  vaginal  operation  for  inversion 
is  the  method  most  commonly  in  use  at  present. 


712 


GYNECOLOGY 


A  transverse  anterior  vaginal  incision  (Fig.  368)  i&  first  made  and  the  bladder 
separated  from  the  uterus,  as  described  for  Anterior  Colpotomy  (see  page  676). 
A  median  incision  is  then  made  through  the  cervix,  dividing  completely  the 
constricting  ring.  This  incision  should  be  carried  toward  the  fundus,  through 
the  anterior  uterine  wall,  until  a  point  is  reached  which  will  allow  the  reinver- 
sion  of  the  uterus.  It  is,  as  a  rule,  necessary  to  continue  the  incision  as  far  as 
the  fundus. 


W,T^G-^ 


Fig.  370. — Spinelli's  Operation  for  Inver- 
sion. 
The  uterus  has  been  reinverted.  In  order 
to  secure  approximation  of  the  edges  of  the 
wound  in  the  uterine  wall  it  has  been  necessary 
to  remove  wedges  of  tissue  on  each  side,  as  is 
shown  in  the  drawing. 


\N  •Pt^ 


Fig.  371. — Spinelli's  Operation  for  Inver- 
sion. 

Closure  of  the  incision  of  the  cervix  and  anterior 
wall. 


The  uterus  is  reinverted  by  placing  the  forefingers  at  the  cervix  for  coun- 
terpressure,  and  forcing  the  fundus  upward  by  the  thumbs  in  the  manner 
that  one  would  naturally  use  in  turning  a  tennis  ball  inside  out  through  a 
cut  in  its  side. 

When  the  uterus  has  been  restored  to  its  original  form,  the  next  step  is  to 
close  the  incision  in  its  wall.  It  will,  however,  be  found  that,  owing  to  the 
shrinking  which  the  peritoneum  has  undergone  in  its  inverted  position,  it  can- 


OPERATIONS    FOR   UTERINE    MALPOSITION 


713 


not  be  approximated,  the  tissue  of  the  uterine  wall  pouting  out  in  the  manner 
of  an  ectropion.  The  excessive  tissue  must  be  trimmed  away  in  the  form  of 
longitudinal  wedges,  as  seen  in  Fig.  370,  when  the  peritoneal  edges  may  be 
coaptated  without  difficulty.  The  wound  of  the  uterine  wall  is  closed  with 
two  rows  of  continuous  catgut  sutures.  The  first  suture  includes  and  firmly 
unites  the  muscular  wall,  while  the  second  is  superficial  and  approximates  the 
peritoneal  surfaces.  The  wound  of  the  cervix  is  closed  wdth  interrupted  catgut 
sutures.     A  cigarette-wick  is  left  in  for  drainage,  as  there  is  always  danger  of 


Fig.  372. — Spixelli's  Oper.\tion  for  Inversion. 
The  vaginal  incision  has  been  sutured  and  a  small  rubber  drain  inserted  at  one  angle. 

sepsis.  Crossen  recommends  drainage  both  from  the  anterior  and  posterior 
culdesac.  The  vaginal  wound  is  sutured  except  for  the  portion  occupied  by 
the  drain. 

HYSTERECTOMY   OPERATIONS 

SUPRAVAGINAL  HYSTERECTOMY 

The  patient  is  in  a  pronounced  Trendelenburg  position.  The  length  of  the 
median  abdominal  incision  depends  upon  the  size  of  the  mass  to  be  removed 
from  the  pelvis.  If  there  is  no  enlargement  of  the  pelvic  organs  the  incision 
need  not  be  greater  than  3|  inches  unless  the  patient  is  fat.     In  all  cases  the 


714 


GYNECOLOGY 


incision  through  the  aponeurosis  should  be  carried  down  as  far  as  possible 
to  the  pubes,  for  it  is  at  the  lower  end  of  the  wound  that  most  room  is 
needed.  The  intestines,  which  should  be  carefully  prepared,  are  walled-  off 
with  gauze.  The  fundus  of  the  uterus  is  then  seized  with  volsella,  unless  there 
is  question  of  infection  or  necrosis  of  the  tissue,  in  which  case  they  should  not 
be  used.  The  uterus  is  first  drawn  sharply  to  the  left,  thus  exerting  tension  on 
the  broad  ligament  and  bringing  the  round  and  infundibulopelvic  ligaments 
into  prominence.  A  single  half-length  clamp  is  apphed  near  the  ovary,  includ- 
ing the  round  ligament  close  to  the  uterus  and  the  infundibulopelvic  ligament, 
in  which  run  the  ovarian  vessels.     The  clamp  should  be  so  applied  that  the  two 


\voun6-)-i\o 


.      \l\.^<oaoX\^ 


Fig.  373. — Supravaginal  Hysterectomy.     First  Step. 
A  single  half-length  clamp  is  placed  on  the  broad  ligament  close  to  the  uterus, 
tying  the  infundibulopelvic  ligament  is  being  placed. 


The  first  ligature  for 


hgaments  meet  each  other  at  an  angle  (Fig.  373).  A  hgature  of  No.  2  catgut  is 
then  passed  with  a  needle  around  the  infundibulopelvic  ligament  and  tied,  the 
needle  entering  the  leaves  of  the  broad  ligament  in  the  so-called  clear  space 
in  which  there  are  no  veins.  The  ligament  is  cut  and  tied  again  to  insure 
against  secondary  hemorrhage  from  the  ovarian  vessels;  the  round  ligament  is 
then  tied  with  one  ligature  and  cut.  After  cutting  the  round  ligament,  the 
region  of  the  uterine  vessels  is  exposed  by  cutting  the  leaves  of  the  broad  liga- 
ment as  close  to  the  round  ligament  as  possible.  If  the  division  of  the  broad 
ligaments  is  carried  down  too  close  to  the  uterus,  several  branches  of  the  uterine 
vessels  are  inevitably  wounded  and  require  extra  clamps  to  control  the  hemor- 


HYSTERECTOMY   OPERATIONS 


715 


rhage.  (It  is  important  to  limit  the  number  of  clamps  as  much  as  possible,  for 
they  greatly  hamper  the  progress  and  smooth  technic  of  the  operation.)  When 
the  leaves  of  the  broad  ligament  have  been  slit  down  close  to  the  round  ligament 
the  edges  fall  apart  and  expose  the  uterine  vessels. 

The  uterus  is  now  drawn  toward  the  right  and  the  left  adnexa  treated  in 
the  same  way.  At  this  stage  of  the  operation  there  are  in  the  wound  only 
the  two  clamps  on  the  uterine  adnexa  in  addition  to  the  traction  forceps  which 
grasps  the  fundus  of  the  uterus.     The  uterus  is  then  drawn  backward,  exposing 


Ivounb  Xi  > 


vaxvawyes 


.Ve 


Fig.  374. — Supravaginal  Hysterectomy. 

Dissection  of  the  uterovesical  fold  of  peritoneum.     The  blades  of  the  scissors  are  pushed  under  the 

peritoneum  before  cutting  it,  thus  avoiding  unnecessary  bleeding. 

the  bladder.  The  uterovesical  reflection  of  peritoneum  is  picked  up  with 
thumb  forceps  close  to  the  bladder,  where  it  is  loosely  attached,  and  opened 
sufficiently  to  admit  the  end  of  a  pair  of  blunt  curved  scissors,  which  are  pushed 
under  the  peritoneum  to  the  cut  surfaces  on  each  side  of  the  uterus  (Fig.  374). 
This  chssects  up  the  peritoneum  so  that  it  is  easily  cut,  with  the  complete  avoid- 
ance of  bleeding.  It  is  not  riecessary  to  dissect  a  flap  of  peritoneum  on  the  posterior 
wall  of  the  uterus. 

The  uterus  is  now  ready  for  amputation.     A  half-length  clamp  is  applied 
to  the  left  uterine  vessels,  where  they  ascend  the  uterus  at  the  level  of  the 


716 


GYNECOLOGY 


internal  os.  A  second,  toothed,  clamp  is  applied  to  the  same  vessels  f  inch 
higher  on  the  uterine  wall,  and  the  vessels  are  severed  close  to  the  second  clamp 
so  as  to  leave"  the  proximal  stump  as  long  as  possible.  The  traction  forceps  on 
the  fundus  of  the  uterus  is  then  seized  in  the  left  hand  of  the  operator  and 
drawn  as  sharply  to  the  right  as  possible  in  order  to  expose  the  cervix  and  give 
room  for  the  amputation.     A  wedge-shaped  incision  is  made  across  the  cervix 


uinn_^ 


Fig.  375. — Supravaginal  Hysterectomy.     First  Step  of  Amputation. 
The  uterine  vessels,  having  been  exposed,  are  grasped  with  two  clamps  and  are  being  severed. 
Care  must  be  taken  to  leave  the  ends  of  the  vessels  sufficiently  long  above  the  lower  clamp  so  that 
they  may  easily  be  seized  by  the  "secondary  defense"  clamp  seen  in  Fig.  379. 


until  the  cervical  tissue  is  entirely  severed.  The  uterus  is  now  held  only  by  the 
right  uterine  vessels  (Fig.  377).  They  are  clamped  and  cut  so  as  to  leave  a  long 
pedicle  beyond  the  clamp.  With  the  removal  of  the  uterus  and  appendages  only 
two  clamps  remain  in  the  pelvis  controlhng  the  uterine  vessels.  A  third,  toothed, 
clamp  is  now  attached  to  the  posterior  lip  of  the  cervical  stump  for  the  purpose 
of  traction.     K  there  is  any  question  about  the  possibility  of  infection  from 


HYSTERECTOMY   OPERATIONS 


717 


the  cervical  canal,  it  may  be  cauterized  or  treated  with  crude  carbolic  acid  or 
alcohol  or  iodin. 

The  lips  of  the  cervical  stump  are  united  with  two  or  three  interrupted  sutures 
and  then  the  uterine  vessels  are  tied.  The  technic  of  tying  these  vessels  is  im- 
portant. While  amputating  the  uterus  pains  were  taken  to  leave  the  pedicles 
of  the  vessels  extending  beyond  the  clamps  as  long  as  possible.  Beginning  now 
on  the  right,  the  redundant  pedicle  of  the  vessels  is  included  in  another  pair  of 


Fig.  376. — Supr.\ vaginal  Hysterectomy.     Second  Step  of  Amputation. 
The  vessels  of  the  left  side  have  been  severed  and  the  uterus  is  being  amputated  by  a  wedge-shaped 

incision. 


clamps  to  act  as  a  sort  of  secondary  defense.  A  ligature  is  introduced  with 
a  full-curved  needle  first  into  the  tissue  of  the  cervix  inside- the  vessels,  then 
around  the  vessels  and'  tied.  As  the  knot  is  tied  the  first  or  lower  clamp  is 
released.  The  ligature  is  then  passed  again  in  the  same  manner,  and  when  tied 
the  secondary  clamp  is  removed.  In  this  manner  the  uterine  vessels  are  tied 
twice.  By  using  the  secondary  clamp  no  blood  is  lost.  The  same  procedure 
is  carried  out  on  the  left. 


718 


GYNECOLOGY 


The  next  step,  and  a  most  important  one,  is  the  suspension  of  the  cervical 
stump  by  the  broad  hgaments  in  order  to  avoid  a  later  prolapse,  a  comphcation 


Fig.  377. — Supravaginal  Hysterectomy. 
The  left  uterines  have  been  clamped  and  cut.     The  uterus  has  been  amputated  by  a  wedge- 
shaped  incision.    The  uterines  of  the  right  side  have  been  reached  and  exposed  by  lifting  the  uterus. 
A  clamp  now  grasps  the  vessels,  which  are  severed  with  as  long  a  pedicle  as  possible. 

which,  as  we  have  emphasized  (see  page  129),  is  the  most  common  cause  for  the 
physical  and  nervous  symptoms  following  hysterectomy. 


HYSTERECTOMY   OPERATIONS 


719 


Fig.  378. — Supravaginal  Hysterectomy. 

The  uterus  has  been  amputated  by  a  wedge-shaped  incision.     Two  or  three  interrupted  sutures  close 

the  walls  of  the  cervical  stump.     The  first  suture  is  being  placed. 


~TiVsl  Tie-' 


\vIP.G--^ 


Fig.  379. — Supra vagixal  HYSTERECTOivrY. 
The  uterines  of  the  right  side  are  about  to  be  tied.     The  "secondary  defense"  clamp  has  been 
appHed  to  the  ends  of  the  vessels.     When  the  Ugature  has  been  tied  the  lower  clamp  is  removed.     A 
second  tie  is  then  made  for  extra  safety. 


720 


GYNECOLOGY 


Beginning  on  the  right,  the  round  and  infundibulopelvic  ligaments,  which 
have  been  tied  so  as  to  meet  each  other  at  an  angle,  are  grasped  with  clamps. 


Fig.  380. — Supravaginal  Hysterectomy. 
The  uterine  body  has  been  amputated.     The  lips  of  the  cervical  stump  have  been  closed  by  two 
interrupted  sutures.     The  right  uterine  vessels  have  been  tied  once  and  the  ligature  is  being  intro- 
duced for  a  second  tie.     The  stump  of  the  uterine  vessels  is  controlled  by  the  "secondary  defense" 
clamp. 


-^TeTxl'OYve-U'cn 


"^OUX-^bXlQ,. 


Vv/.TtG.. 


3^Q\)Q\as 


\  CatuiccxX  btuvA'^ 


Fig.  381. — Supravaginal  Hysterectomy. 

The  stumps  of  the  broad  ligam,ent  have  been  sewed  to  the  stump  of  the  cervix.     The  bladder  flap  of 

peritoneum  is  being  lifted  up  preparatory  to  stitcliing  it  to  the  posterior  wall  of  the  cervical  stump. 

A  strong  catgut  hgature  is  applied  on  a  needle  which  first  passes  through  the 
tissue  of  the  cervical  stump,  then  through  the  round  hgament  near  the  tied 
end,  and  including  a  little  of  the  peritoneum  covering  the  infundibulopelvic 


HYSTERECTOMY    OPERATIONS 


f21 


Vr:pGr-      ^'""^^  °^  l3ou|>\a?. 


Fig.  382. — Supra. vagixal  Hxstehectomt. 
Operation  completed.     The  bladder  flap  of  peritonexim  has  been  attached  with  one  suture  to  the 

Dosterior  wall  of  the  cer^■ical  stump. 


^\a^ber 


vlovinb  li'^p  • 


""^V^ecxrvb  Ooaru 


Fig.  383. — Supravaginal  Htsteeectomt. 
Method  of  lea^dng  in  the  adnexa  of  both  sides. 


ligament.     The  cendcal  stump  and  the  ends  of  the  two  Hgaments  are  approxi- 
mated and  the  ligature  is  tied.     The  needle-end  of  the  hgature  is  left  long,  and 


46 


722 


GYNECOLOGY 


again  passed  through  the  cervix  and  around  the  ends  of  the  ligaments  of  the 
left  side,  which  are  also  tied  to  the  cervical  stump  in  the  same  way. 

The  final  step  of  the  operation  is  to  grasp  the  loose  flap  of  peritoneum  which 
is  reflected  over  the  bladder,  and  draw  it  up  toward  the  wound.  This  gives  a 
chance,  by  the  translucency  of  the  peritoneum,  to  determine  just  where  the 
edge  of  the  bladder  lies.  A  suture  is  passed  through  the  margin  of  the  per- 
itoneum, across  the  posterior  wall  of  the  cervix,  and  out  again  through  the 
margin.     When  tied  t>he  peritoneal  flap  covers  the  united  cervical  and  liga- 


FiG.  384. — Vaginal  Drainage  After  Supra-vaginal  Amputation. 
The  stump  of  the  cervix  is  drawn  upward  and  forward  by  a  toothed  clamp  inserted  in  the  pos- 
terior wall.     A  long  clamp  has  been  introduced  into  the  vagina,  pressed  against  the  posterior  wall,  and 
unclasped.     An  incision  is  being  made  through  the  vaginal  wall  between  the  opened  ends  of  the  clamp. 

mentary  stumps  and  is  attached  to  the  posterior  surface  of  the  cervix  (Fig.  382) . 
This  completes  the  operation.  By  this  technic  very  little  blood  is  lost,  and  the 
cervix  and  vagina  are  permanently  held  in  a  high  position  in  the  pelvis. 

An  additional  point  of  value  in  the  technic  is  that  only  one  catgut  knot  is 
left  exposed  and  is  in  a  position  where  it  can  do  little  harm.  This  is  an  im- 
portant factor  in  the  avoidance  of  postoperative  adhesions. 

In  sewing  up  the  abdominal  wound  after  an  operation  in  the  Trendelenburg 
position  the  patient  should  be  returned  to  the  horizontal  position  before  the 
skin  and  fat  are  sutured.      It  will  be  found  in  most  cases  when  this  is  done  that 


HYSTERECTOMY    OPERATIONS 


723 


on  account  of  the  change  in  position  a  httle  bleeding  takes  place  from  the 
subcutaneous  vessels  which  require  tying.  If  this  precaution  is  not  taken  it 
will  happen  occasionally  that  the  skin  sutures  will  not  control  this  adventitious 
bleeding,  and  a  blood-clot  will  form  in  the  wound  which  may  cause  delay  in 
the  convalescence. 

Vaginal  Drainage. — Whenever  drainage  of  the  pelvis  is  necessary  it  should 
be  made,  if  possible,  through  the  vagina.  Abdominal  drainage  should  be  resorted 
to  only  in  the  most  severe  inflammatory  cases,  or  when  the  posterior  culdesac 


IBiab^er 


^'  W.P.Grawes- 


Fig.  385. — Vaginal  Drainage  After  Supravaginal  Htsterectomt. 
The  tips  of  the  clamp  in  the  vagina  are  seen  just  emerging  through  the  opening  in  the  posterior  vaginal 

wall. 


is  SO  occluded  with  adhesions  that  opening  the  vagina  would  entail  too  great 
risk  of  injuring  the  rectum. 

The  method  of  instituting  vaginal  drainage  during  the  operation  of  supra- 
vaginal hysterectomy  is  as  follows: 

After  the  cervical  stump  has  been  closed  and  the  uterine  vessels  have  been 
tied,  an  assistant  introduces  into  the  vagina  a  long  curved  clamp  with  the  tip 
turned  toward  the  abdominal  wound  (Fig.  384).  As  the  introduction  of  the 
clamp  must  be  made  under  the  operating  sheet  covering  the  patient,  th,e  assist- 


724 


GYNECOLOGY 


ant  must  be  careful  not  to  enter  the  urethra  instead  of  the  vagina.  The  stump 
of  the  cervix  is  drawn  strongly  upward  and  the  ends  of  the  clamps  are  pressed 
against  the  posterior  vaginal  wall  near  the  cervix.  The  clamp  is  then  unclasped 
and  the  surgeon  makes  an  incision  between  the  ends  of  the  clamp  through  the 
vaginal  wall  (Fig.  384).  The  assistant  closes  the  clamp,  forces  it  through  the 
vaginal  opening  into  the  posterior  culdesac  and  receives  a  cigarette-drain,  which 
he  draws  down  into  the  vagina  (Fig.  386).  The  rest  of  the  operation  is  then 
completed  and  the  abdominal  wound  closed.     In  most  cases  the  drain  is  removed 


Tlidtavcuon  C\a\np 
on  SVomoofCiiroix.  . 


Fig.  3bD. — Vaginal  Drainage  After  Supravaginal  Hysterectomy. 
A  cigarette  drain  is  being  passed  by  the  surgeon  to  a  clamp,  which  has  penetrated  an  opening  made  in 

the  posterior  vaginal  wall. 

in  two  or  three  days  and  does  not  have  to  be  replaced.  By  this  method  of  drain- 
ing the  pelvis  the  time  of  convalescence  of  the  patient  is  not  lengthened  beyond 
that  of  cases  where  drainage  is  not  required. 


COMPLETE  HYSTERECTOMY 


Except  for  malignant  disease,  complete  hysterectomy,  which  implies  an 
extirpation  of  the  cervix  together  with  the  uterine  body,  is  seldom  necessary. 
There  are,  however,  certain  conditions  which  make  the  removal  of  the  cervix 
desirable,  conditions  that  sometimes  cannot  be  foreseen  before  the  abdomen  is 


HYSTERECTOMY    OPERATIONS 


725 


opened  for  operation.  On  account  of  the  possibility  of  indication  for  complete 
hysterectomy,  and  consequent  exposure  of  the  vaginal  mucous  membrane,  the 
vagina  should  always  be  thoroughly  prepared  before  a  pelvic  operation  which 
by  any  chance  may  involve  a  hysterectomy. 

One  of  the  conditions  that  make  a  removal  of  the  cervix  advisable  is  a 
chronic  endocervicitis  associated  with  pelvic  inflammatory  disease.     In  most 


Vite-rvne. 
"Vessels 


Fig.  387. — Hysterectomy  with  Removal  op  the  Cervical  Canal. 
The  uterine  vessels  have  been  tied  (or  clamped)  and  cut.     The  cervical  canal  is  being  "coned"  out 

with  a  knife. 

cases  such  an  endocervicitis  heals  spontaneously  after  a  supravaginal  hyster- 
ectomy, but  occasionally  the  inflammation  persists  and  the  patient  continues 
after  the  operation  to  suffer  from  an  irritating  leukorrhea.  This  unpleasant 
consequence  may  be  avoided  by  a  removal  during  the  operation  of  the  cervical 
mucous  membrane,  which  can  be  accomphshed  either  by  performing  a  complete 
hysterectomy,  as  described  below,  or,  better  and   more  simply,  by  "coning" 


726 


GYNECOLOGY 


out  the  cervical  mucosa,  as  depicted  in  Fig.  387.  This  latter  maneuver  is  espec- 
ially valuable  in  pelvic  inflammatory  cases  in  which  there  has  been  parametritic 
infiltration,  making  the  complete  removal  of  the  cervix  a  difficult  and  dangerous 
procedure. 


Fig.  388; — CoMPiiETE  Hysterectomy. 
The  vessels  have  been  tied  and  cut  and  the  bladder  dissected  from  the  anterior  cervical  wall. 
The  paranietrium  is  grasped  on  each  side  with  pressure  forceps  and  di-\aded  close  to  the  cervix  and 
vagina.     A  small  longitudinal  incision  has  been  made  exposing  the  vaginal  portion  of  the  cervix. 
The  vagina  is  divided  in  a  circular  direction,  starting  from  the  small  incision. 

The  operation  of  coning  the  cervical  mucosa  is  performed  in  the  follow- 
ing way:  All  the  preliminary  steps  of  a  supravaginal  amputation  are  carried 
out  as  described  above.  Then,  instead  of  amputating  the  uterine  body  in  the 
usual  way,  it  is  dissected  away  by  s,  deep  circular  incision  in  the  tissues  of  the 
cervix  extending  to  the  portio,  so  that  most  of  the  cervix  is  removed  with  the 


HYSTERECTOMY    OPERATIONS 


727 


uterus  in  the  form  of  a  cone-shaped  wedge,  including  all  of  the  cer\acal  mucous 
membrane.  By  this  method  very  httle  bleeding  is  encountered  and  there  is 
absolutely  no  danger  of  injuring  the  ureters.  As  onty  a  minimum  of  vaginal 
surface  is  exposed,  the  wound  in  the  cervix  may  usually  be  closed  as  in  an 
ordinary  supravaginal  hysterectomy  without  drainage,  pro\'ided,  of  course, 
there  has  been  proper  preliminary  preparation  of  the  vagina.     If  it  seems  de- 


FiG.  389. — CoiiPLETE  Hysterectomy. 

The  cervix  has  been  grasped  by  the  anterior  wall  and  delivered  through  the  opening  in  the  vagina. 

The  posterior  wall  of  the  vagina  is  about  to  be  severed  with  scissors. 


sirable  to  drain,  it  may  be  done  as  in  the  operation  for  complete  hysterectomy 
described  below. 

Complete  hysterectomy  is  indicated  in  certain  cases,  of  myoma  invohing  the 
cervix,  or  when  a  severe  laceration  of  the  cer\ax  is  present,  or  when  the  gross 
appearance  of  the  fundus  suggests  the  presence  of  adenocarcinoma.  Some 
cases  of  malignant  disease  of  the  ovaries  or  of  extensively  adherent  intra- 
ligamentary  cj^sts  require  complete  hysterectomy. 


728  GYNECOLOGY 

The  Steps  of  the  Operation. — The  adnexa  and  uterine  vessels  are  secured 
and  ligated  as  in  the  operation  of  supravaginal  hj^sterectomy.  The  utero- 
vesical  plica  of  peritoneum  is  divided,  and  the  bladder  stripped  away  from  the 
cervix  and  upper  vagina  by  blunt  scissors  dissection.  The  parametria!  tissue 
is  then  clamped  very  close  to  the  cervix,  extreme  care  being  taken  not  to  include 
the  ureters,  which  should,  if  possible,  be  definitely  located  before  applying  the 
clamps.  The  parametrial  tissue  is  divided  on  each  side.  The  end  of  the  cervix 
is  determined  by  palpation  with  the  thumb  and  forefinger,  the  vaginal  canal 
opened  close  to  the  portio,  and  the  uterus  removed  by  circular  incision  of  the 
vaginal  wall.  Crossen's  technic  of  this  part  of  the  operation  is  shown  in  Fig. 
388. 

If  the  vagina  has  been  carefully  prepared  beforehand,  and  there  is  no  exuda- 
tion from  the  uterine  canal  during  the  operation,  it  is  sometimes  safe  enough  to 
close  the  vaginal  wound  without  drainage.  As  a  rule,  however,  it  is  advisable 
to  place  a  drain  subperitoneally  as  follows :  The  edges  of  the  vaginal  wound  are 
carefully  wiped  with  alcohol.  If  by  some  error  there  has  been  no  previous  vaginal 
preparation,  the  upper  exposed  part  of  the  vagina  should  be  treated  with  iodin 
after  first  thoroughly  protecting  with  gauze  the  surrounding  parts  of  the  pelvis. 
The  corners  of  the  vaginal  wound  are  closed  with  interrupted  catgut  sutures, 
leaving  a  central  aperture  through  which  a  cigarette-drain  is  placed.  The 
broad  ligaments  are  then  sewed  to  the  angles  of  the  vaginal  stump,  wliile  the 
uterovesical  flap  of  peritoneum  is  drawn  over  the  whole  and  stitched  to  the 
back  of  the  vagina  in  the  pouch  of  Douglas.  In  this  way  protective  drainage 
is  secured,  while  the  vagina  is  suspended  by  the  broad  ligaments  for  the  preven- 
tion of  a  later  prolapse.  The  vaginal  drain  may  usually  be  removed  in  thirty- 
six  to  forty-eight  hours  unless  there  is  special  danger  of  sepsis,  in  which  case  it 
is  left  in  according  to  the  exigencies  of  the  case. 

After  finishing  the  portion  of  the  operation  involving  the  closure  of  the 
vaginal  wound  it  is  advisable  for  the  surgeon  to  change  gloves  and  instruments 
after  removing  the  gauze  placed  for  protection  of  the  pelvis. 

VAGINAL  HYSTERECTOMY 

As  compared  with  a  properly  executed  abdominal  hysterectomy,  the  extir- 
pation of  the  uterus  per  vaginam  has  no  advantages.  It  cannot  be  done  more 
rapidly,  and  there  is  no  less  shock  or  loss  of  blood,  though  claims  to  the  contrary 
are  sometimes  made.  Vaginal  hysterectomy  is  useful  in  some  types  of  operation 
for  procidentia. 

Steps  of  the  Operation. — The  cervix  is  grasped  by  a  traction  forceps  and 
drawn  firmly  down  toward  the  introitus.  A  cross-incision  is  made  at  the  line 
of  junction  of  the  bladder  and  anterior  cervical  wall.  The  bladder  is  then 
stripped  from  the  cervix  and  the  uterovesical  pouch  opened.  The  traction  for- 
ceps is  removed  from  the  cervix,  and  the  cervix  is  itself  pushed  back  in  the 


HYSTERECTOMY    OPERATIONS 


729 


vagina,  so  as  to  antevert  the  uterus.     The  fundus  is  thus  -brought  into  view, 
seized  with  volsella,  and  brought  out  through  the  opening  in  the  uterovesical 


Fig.  390.' — ^Vaginal- Hysterectomy. 

Transverse  incision  of  the  vaginal  wall  at  the  junction  of  bladder  and  cervix.     Stripping  back  the 

bladder  (adapted  from  Doderlein-Kronig) . 


pouch.  Mass  ligatures  are  now  placed  on  the  broad  ligament,  including  the 
round  hgament  tube  and  suspensory  ligament  of  the  ovary,  which  are 
severed  near  the  uterus.      The  parametrium  is  -divided  on  the  sides  of  the 


730 


GYNECOLOGY 


uterus,  thus  exposing  the  uterine  vessels,  which  are  tied  and  cut.  Several 
stitches  are  placed  in  the  stump  of  the  parametrium  on  each  side,  attaching 
it  to  the  sides  of  the  vaginal  wound.  The  uterus  is  now  drawn  strongly  forward 
and  the  pouch  of  Douglas  exposed.  With  the  uterus  in  this  position  the  pos- 
terior wall  of   the  vagina  is  easily  divided.      During   this  incision  there  is 


Fig.  301. — Vaginal  Hysterectomy. 
Opening  the  utero vesical  space  (after  Doderlein-Kronig). 


some  bleeding  from  the  vaginal  vessels,  which  should  be  controlled  as  the 
uterus  is  removed.  The  round  ligaments  are  then  sewed  into  the  corners  of  the 
vaginal  wound.  This  is  an  important  step,  for  it  prevents  to  some  extent  a 
later  prolapse  of  the  vaginal  wall.  The  anterior  and  posterior  vaginal  walls  are 
approximated  by  interrupted  catgut  sutures. 


HYSTERECTOMY    OPERATIONS 


731 


WERTHEIM'S  EXTENDED  OPERATION  FOR  CANCER  OF  THE  UTERUS 

The  Wertheim  operation  is  used  both  for  cancer  of  the  cervix  and  cancer  of 
the  body  of  the  uterus.  Its  chief  object  is  to  remove  with  the  uterus  as  much 
of  the  parametria!  tissue  as  possible  and  to  include  a  wide  margin  of  the  vagina. 

The  description  of  the  operation  given  below  applies  to  cancer  of  the  cervix. 
For  cancer  of  the  body  the  same  technic  may  be  applied,  but  the  dissection  of 
the  parametrium  and  the  vaginal  margin  need  not  be  so  extensive. 


Fig.  302. — Vacunal  Hysterectomy. 
Tying  off  the  adnexa. 

Before  operating  on  a  case  of  cancer  of  the  cervix,  especially  of  the  everting 
type,  it  is  usually  necessary  to  remove  the  necrotic  excrescent  growth  from  the 
vagina.  By  the  original  Wertheim  method  this  is  done  without  anesthesia 
immediately  before  the  performance  of  the  radical  operation.  Some  curet 
the  cervix  just  before,  with  the  patient  under  anesthesia.  It  is  our  custom  to 
do  the  prehminary  cureting  under  light  narcosis  about  a  week  or  ten  days  before 
attempting  the  main  operation. 

In  performing  the  preliminary  operation  the  chief  object  is  to  remove 
merely  the  main  bulk  of  the  cancerous  mass  in  order  to  facilitate  the  later  opera- 
tion, and  to  leave  the  cancerous  field  so  that  it  can  be  made  as  clean  as  possible 


732 


GYNECOLOGY 


/ 


/■ 


Fig.  393. — Vaginal  Hysterectomy. 
The  broad  ligament  and  the  upper  part  of  the  parametrium  have  been  divided.     The  under 
part  of  the  parametrium  and  posterior  vaginal  waU  are  about  to  be  divided  (adapted  from  Doderlem- 
Kronig) . 


HYSTERECTOMY    OPERATIONS 


733 


during   the   days   intervening   before   the   radical   operation.     The   cancerous 
masses  are  removed  with  a  large  curet,  but  the  curet  is  not  carried  too  deeply 


^(M:?.G^.  a^Wv 


Fig.  394. — Vaginal  Hysterectomy. 
Division  of  the  posterior  vaginal  wall  (adapted  from  Doderlein-Kronig) 

into  the  surrounding  tissue  wall,  for  if  this  is  made  too  thin  it  is  liable  to  be  rup- 
tured by  the  tension  on  the  uterus  necessary  in  the  course  of  the  later  operation. 
Another  important  reason  for  a  not  too  thorough  cureting  is  the  possible  danger 


734 


GYNECOLOGY 


of  penetrating  the  peritoneal  cavity,  an  accident  which,  on  account  of  the  viru- 
lent organisms  always  contained  in  the  cancerous  mass,  is  almost  inevitably 
followed  by  a  fatal  peritonitis.  -      '- 

The  preliminary  operation  should  be  regarded  also  as  a  cureting  and  not 
as  a  cauterization,  for  if  the  latter  is  done  a  slough  is  produced,  which  during 
its  separation  produces  an  unclean  discharge,  that  acts  as  a  source  of  danger 
during  the  later  operation.     After  cureting  away  the  cancerous  masses  the 


Fig.  395. — Vaginal  Hysterectomy. 

Sewing  the  peritoneum  to  the  vaginal  stump.     The  broad  ligaments  have  been  stitched  to  the  -vagina 

on  each  side  (adapted  from  Doderlein-Kronig) . 


crater  is  packed  with  iodoform  gauze  to  prevent  unnecessary  loss  of  blood.  If 
the  bleeding  is  considerable  the  vagina  should  also  be  packed.  In  about  twenty- 
four  hours  the  packing  is  removed.  During  the  interval  before  the  main  opera- 
tion formalin  douches  (1  to  2  per  cent.)  are  given  daily.  The  patient  is  kept 
out  of  doors  as  much  as  possible  and  supporting  treatment  given  for  about  a 
week  or  ten  days. 

The  Operation. — A  thorough  bowel  preparation  is  very  necessary,  so  that 
the  intestines  may  be  well  collapsed  at  the  time  of  operation.     The  catharsis 


HYSTERECTOMY    OPERATIONS  735 

should  be  given  the  second  night  before  the  operation^  so  that  the  patient  may 
have  an  undisturbed  night  preceding  the  operation.  The  usual  abdominal  and 
vaginal  preparation  is  carried  out.  When  the  patient  has  been  anesthetized 
the  vagina  is  wiped  dry  and  then  thoroughly  painted  with  iodin.  It  is  not 
necessary  to  leave  a  gauze  packing  in  the  vagina  if  the  iodin  application  is 
properly  done. 

In  performing  the  operation  it  is  important  to  carry  out  a  very  systematic 
line  of  procedure  in  order  to  save  as  much  time  as  possible. 


Nj^'^-Cr—, 


Fig.  396. — Vaginal  Hystkkectomy.     Final  Step. 
Suturing  thie  anterior  and  posterior  walls  of  the  vagina. 

(1)  Opening  the  Abdominal  Cavity. — It  is  advantageous  to  have  the  patient 
in  a  steep  Trendelenburg  position,  which  in  our  experience  does  not  possess 
the  dangers  very  commonly  attributed  to  it.  It  is  important  that  the  weight  of 
the  patient  should  be  partly  supported  by  well-padded  shoulder-braces.  The 
abdomen  niay  be  opened  by  a  very  long  median  incision  reaching  from  the 
pubes  to  the  umbilicus.  This  is  the  incision  usually  employed  in  this  country, 
and,  as  a  rule,  gives  plenty  of  room.  The  transverse  incision  carried  directly 
across  the  abdominal  muscles,  as  depicted  in  Fig.  397,  exposes  the  field  of  opera- 
tion more  completely  than  does  the  longitudinal  opening.     We  have  not  found 


736 


GYNECOLOGY 


V^Grck\)es.iC)v5' 


\     % 


KJ~/. 


v^ 


u/^ 


/ri 


I  I 


X. 


\ 


V 


""''^*, 


< 


\ 

Fig.  397.— Transverse -Incision  for  Cancer  of  the  Cervix. 
The  abdominal  muscles  have  been  severed  from  spine  to  spine.     T^e  peritoneum  has  been 
split  from  the  abdominal  wall  and  stitched  down  so  as  to  protect  the  intestines  from  the  field  of 
operation. 

it  necessary  to  resort  to  this  method.  In  our  work  we  have  had  no  trouble  with 
necrosis  and  sloughing  of  the  abdominal  wound  from  prolonged  retraction 
pressure   during  the   operations.     This   complication,   however,   is  mentioned 


HYSTERECTOMY  OPERATIONS 


737 


by  numerous  operators,  and  various  means  of  protecting  the  wound  are  em- 
ployed, red  sheet-rubber  being  especially  recommended.  .Wertheim  avoids  the 
difficulty  by  not  using  metal  retractors,  the  sides  of  the  wound  being  held 
back  by  the  hands  of  his  assistant. 


liiG.  3y». — Wertheim's  Operation  for  Cancer  of  the  Cervix. 

Stripping  the  bladder  from  the  anterior  wall  of  the  cervix  and  vagina.     This  should  be  done  by  blunt 

dissection  with  scissors,  never  with  gauze. 


Some  protect  the  intestines  by  turning  down  a  wide  flap  of  peritoneum  from 
the  anterior  abdominal  wall  and  stitching  it  to  the  peritoneum  of  the  posterior 
pelvic  wall,  as  is  seen  in  Fig.  397.     This  we  have  not  found  necessary. 

(2)  Ligature  of  the  Broad  Ligaments. — The  broad  ligaments  are  tied  in  the 
same  manner  as  that  described  for  supravaginal  hysterectomy,  except  that 
if  the  operation  is  for  cancer  of  the  cervix  the  ligatures  around  the  inf undibulo- 

47 


738  GYNECOLOGY 

pelvic  atid  round  ligaments  are  placed  at  a  greater  distance  from  the  uterus. 
This  is  done  in  order  to  remove  a  large  amount  of  parametrial  tissue.  If  the 
operation  is  for  cancer  of  the  body,  where  the  'dissection  does  not  need  to  be  so 
wide,  the  two  ligaments  may  be  tied  and  severed  near  the  uterus,  as  in  supra- 
vaginal hysterectomy.  They  can  then  be  used  to  sew  into  the  angles  of  the 
vaginal  stump  in  order  to  prevent  a  future  prolapse  of  the  vagina. 

In  cancer  of  the  cervix  operations,  however,  it  is  necessary  to  cut  the  liga- 
ments so  wide  that  they  are  not  available  for  suspending  the  vagina. 

(3)  Separating  the  Bladder. — After  the  broad  hgaments  have  been  tied  and 
cut,  the  bladder  is  separated  from  the  anterior  wall  of  the  cervix  and  vagina. 
The  uterovesical  peritoneal  reflection  is  first  picked  up  with  thumb  forceps  in 
the  middle  line  at  a  point  where  it  can  be  easily  lifted  away  from  the  underlying 
tissues;  a  nick  is  made  in  the  peritoneum,  and  the  blunt  end  of  a  pair  of  scissors 
introduced  beneath  the  peritoneum,  stripping  it  up  toward  each  round  Hgament. 
The  peritoneum  is  cut  across,  exposing  the  fold  of  bladder  that  is  attached 
to  the  cervix  and  vagina.  The  bladder  is  then  dissected  away  from  its  uterine 
and  vaginal  attachments  and  not  stripped  off  with  gauze.  The  dissection  is 
best  carried  out  with  blunt  scissors,  partly  by  blunt  dissection  and  partly  by 
cutting  the  firmer  strands  of  tissue. 

This  manner  of  freeing  the  bladder  we  regard  as  of  great  importance  in  the 
technic,  for  the  use  of  gauze  dissection  is  a  source  of  much  danger  to  the  bladder, 
not  only  in  the  way  of  actually  rupturing  the  bladder  wall,  but  in  'so  traumatizing 
the  sfnall  vessels  of  the  wall  as  to  result  in  later  cystitis  or  ulceration  (see  also 
page  262). 

The  separation  of  the  bladder  should  be  carried  down  as  far  as  possible; 
small  bleechng  vessels  should  be  tied  at  once  with  fine  catgut.  A  complete 
separation  of  the  bladder  cannot  be  made  at  this  stage. 

(4)  Identification  of  Ureters  and  Ligation  of  Uterine  Vessels. — When  the 
bladder  has  been  dissected  away  as  far  as  possible,  the  uterus  is  held  forward 
and  to  the  left,  exposing  the  right  side  of  the  pelvis.  The  next  step  is  to  identify 
clearly  the  right  ureter.  The  two  layers  of  the  broad  ligament  are  separated 
and  the  cellular  tissue  between  them  gently  cleared  with  the  blunt  end  of  the 
scissors.  In  favorable  cases  the  ureter  is  plainly  seen  lying  at  the  base  of  the 
sulcus  between  the  two  layers  of  the  broad  hgament.  Usually,  however,  it  is 
not  at  first  easily  visible,  and  requires  some  search.  It  may  best  be  found  by 
picking  up  the  posterior  layer  of  the  broad  ligament  and  rolling  the  tissue 
between  the  thumb  and  forefinger,  when  it  can  usually  be  felt  as  a  soft,  non- 
pulsating  cord.  Some  operators,  after  identifying  the  ureter,  free  it  and  lift 
it  from  its  bed  by  passing  under  it  a  strip  of  gauze  or  a  ligature  or  some  curved 
instrument.  We  are  accustomed  to  strip  the  ureter  as  Httle  as  possible,  as  inter- 
ference with  its  blood-supply  predisposes  to  necrosis  and  ureteral  fistula.  When 
the  ureter  has  been  isolated,  the  next  step  is  to  tie  the  uterine  vessels.  With 
the  ureter  as  a  guide,  the  forefinger  is  passed  beneath  the  uterine  vessels  in  the 


HYSTERECTOMY    OPERATIONS 


739 


direction  of  the  bladder,  and  then  pushed  forward  until  it  emerges  through  the 
cellular  connective  tissue  lying  between  the  uterine  vessels  and  bladder  (Fig. 
400). 

The  first  part  of  this  maneuver  is  comparatively  easy,  but  the  final  protru- 
sion of  the  finger  through  the  last  layer  of  tissue  is  attended  with  considerable 
difl&culty,  and  in  cases  of  chronic  parametritic  inflammation,  or  especially  after 
radium  treatment,  it  is  almost  impossible.     If  the  forefinger  cannot  be  pushed 


Fig.  399. — Wertheim's  Operation  for  Cancer  of  Cervix. 
Exposure  of  the  right  ureter.     The  two  leaves  of  the  broad  ligament  are  separated  and  the 
ureter  brought  into  view  by  blunt  dissection.     It  always  lies  in  the  posterior  leaf  and  can  easily  be 
palpated  by  the  thumb  and  forefinger. 


tnrough  in  the  classic  way  the  opening  may  be  made  by  a  blunt  ligature-carrier 
or  by  a  clamp  devised  by  the  author  for  this  purpose  and  depicted  in  Fig.  402) 
When  the  finger  has  been  properly  looped  about  the  vessels  the  pulsation  of 
the  uterine  artery  can  easily  be  felt.  The  vessels  are  then  lifted  away  from  the 
ureter  and  freed  as  far  as  possible  toward  the  pelvic  wall.  A  double  ligature  is 
passed  and  tied  and  the  vessels  cut  between  the  two  hgatures.  The  ureter  and 
its  point  of  entrance  into  the  bladder  are  now  freely  exposed,  and  an  oppor- 


f40 


GYNECOLOGY 


tunity  given  for  separating  by  blunt  dissection  the  ureter  and  angle  of  the 
bladder  from  the  lateral  wall  of  the  vagina.  This  procedure  helps  to  carry  out 
still  further  step  No.  3 — i.  e.,  the  separation  of  the  bladder  from  the  vagina, 
which  it  was  said  was  necessarily  left  incomplete. 

The  isolation  of  the  ureter,  hgation  of  the  uterine  vessels,  and  separation  of 
the  ureter  and  bladder  from  the  side  of  the  vagina  are  repeated  on  the  left  side. 


"U-Xvtc 


"IB\abber 


IftrRoun'bla.^       ' 


Ctxnter 


^-CRounb  J-ii0 


"RvQht  LRe,nne 
-  ^'    Vessels 


^'^.'PCB  X  csA)  es , 


Fig.  400. — Webtheim's  Operation  for  Cancer  of  the  Cervix. 
The  broad  ligaments  have  been  tied  and  cut.     The  bladder  has  been  dissected  from  the  cervix. 
The  right  ureter  is  exposed.     The  forefinger  is  being  introduced  between  the  ureter  and  uterine  ves- 
sels.    The  point  of  the  forefinger  is  forced  through  the  cellular  tissue  in  front  of  the  vessels. 


(5)  Separation  of  the  Rectum  and  Final  Dissection  of  the  Parametrial  and 
Paravaginal  Tissue. — The  uterus  is  now  drawn  strongly  forward,  exposing  as 
well  as  possible  the  pouch  of  Douglas.  The  peritoneum  at  the  bottom  of  this 
pouch  is  picked  up  and  cut,  and  the  blunt-pointed  scissors  inserted  beneath  the 
peritoneum,  as  in  separating  the  utero vesical  reflection.  The  peritoneum  is  in 
the  same  way  cut  across  from  broad  ligament  to  broad  ligament,  exposing  the 


HYSTERECTOMY    OPERATIONS 


741 


uterosacral  ligaments.  Clamps  are  placed  on  the  ligaments  and  the  tissue 
severed.  On  cutting  these  ligaments  the  uterus  is  noticeably  released.  The 
rectum  is,  as  a  rule,  easily  separated  from  the  vagina,  as  there  exists  between 
them  only  a  loose  cellular  tissue  connection. 

After  freeing  the  rectum,  the  remaining  parametrial  and  paravaginal-  attach- 
ments on  the  sides  and  back  of  the  vagina  are  successively  clamped  and  cut. 


^^i-TvaubuS  \jte.X\ 


1VvQV;t  UteviYieS.  CuV- 


\i^\.  Ufeter 


^  'Urete 


"!Doug\a9. 


"^ooCtVvj cxo in C\V  iisSufc 


^*  WT?fera\je<^  — 


Fig.  401. — Wertheim's  Operation  for  Cancer  of  the  Cervix. 
The  uterine  vessels  of  both  sides  have  been  ligated  and  tied  and  the  ureters  exposed.     The 
recto-uterine  reflection  of  peritoneum  has  been  divided.      The  uterosacral  ligaments  have  been 
clamped  and  are  being  severed.     The  paravaginal  tissue  is  exposed. 

the  uterine  mass  being  more  and  more  released  at  each  cut.  At  this  stage,  before 
finally  clamping  and  removing  the  mass,  the  bladder,  especially  at  the  points 
of  entrance' of  the  ureters,  can  be  still  further  separated  from  the  vagina. 

(6)  Clamping  and  Amputation  of  the  Vagina.— When  the  dissection  has  been 
carried  down  the  vagina  as  far  as  possible,  always  to  a  considerable  distance 
below  the  site  of  the  cancer,  the  vagina  is  to  be  amputated.     It  is  an  excellent 


742 


GYNECOLOGY 


safeguard  at  this  point  to  insert  on  each  side  of  the  vagina,  just  below  the  level 
of  the  proposed  line  of  amputation,  strong  catgut  hgatures,  the  ends  of  which 
are  left  long  and  clamped.     These  ligatures  serve  as  tractors  to  prevent  the 


I 


/  .^\i^^ 


~?)\abber 


Sulufe 


W.'P'orcvve 


Fig.  402. — Wertheim's  Opbr.\tion  for  Cancer  of  the  Cervix. 
The  uterus  and  vagina  have  been  freed.  Traction  sutures  have  been  applied  to  the  vaginal  wall 
to  hold  it  into  view  after  amputation.  The  author's  special  clamp  has  been  applied  to  the  vagina 
below  the  seat  of  the  growth.  Wertheim  clamps  have  been  applied  below.  These  latter  may  be 
omitted  if  there  is  deficient  vaginal  margin.  Amputation  is  made  between  the  clamps  with  knife 
or  cautery. 

retraction  of  the  vaginal  stump  after  amputation,  and  also  to  control  the  bleed- 
ing which  is  apt  to  come  from  the  vaginal  angles. 

In  order  to  prevent  the  escape  from  the  cancerous  field  of  possible  infectious 


HYSTERECTOMY    OPERATIONS 


743 


material  the  vagina  must  be  effectively  shut  off  for  its  entire  width.  To  accom- 
phsh  this  numerous  clamps  have  been  devised,  notably  the  right-angled  clamps 
of  Wertheim.  Berkeley  and  Bonney  use  a  large  T-clamp,  which  appears  to  be 
an  excellent  device.  In  the  drawing  (Fig.  402)  the  vagina  is  clamped  above  and 
below,  the  amputation  being  made  between  the  clamps.  This  has  been  the 
author's  technic,  but  with  a  thorough  vaginal  preparation,  such  as  is  described 
above,  it  is  probably  better  to  dispense  with  the  lower  set  of  clamps,  as  without 
them  more  of  the  vagina  can  be  removed.     Their  presence,  however,  insures  for 


vi  V  \:U  two 


^W'bbvir 


Vl.'^G.>f(x\ie'=^ 


"^(LcXuvn- 


Fig.  403. — Wertheim's  Operation  for  Cancer  of  the  Cervix. 
Two  cigarette  -^\acks  have  been  placed  in  the  opening  of  the  vagina.    The  vaginal  walls,  held  up 
into  view  by  traction  ligatures,  have  been  sutured  on  each  side  of  the  wicks.    The  peritoneal  edges 
are  to  be  stitched  together  over  the  wicks,  thus  shutting  them  off  from  the  peritoneal  cavity. 


safety  both  in  controlling  hemorrhage  from  the  vaginal  veins  and  in  preventing 
possible  infectious  material  escaping  from  the  lower  vaginal  section  into  the  ab- 
dominal cavity.  If  the  lower  clamps  are  not  used,  gauze  should  be  stuffed  into 
the  vagina  as  soon  as  it  is  opened. 

After  amputation  of  the  vagina  Hgatures  are  passed  around  the  masses  of 
paravaginal  tissue  included  in  the  clamps.  The  vagina  is  partially  closed  by 
interrupted  sutures,  a  small  opening  being  left  in  the  middle. 

(7)  Drainage  and  Closure  of  the  Peritoneum— -li  is  the  safest  plan  to  drain 
the  paravaginal  space.     This  is  done  by  passmg  into  the  vaginal  opening  a  loop 


744  GYNECOLOGY 

of  Penrose  drainage-tubing,  which  is  caught  and  drawn  down  by  an  assistant, 
who  seizes  it  with  a  long  forceps  inserted  in  the  vagina  from  below.  This  leaves 
the  two  ends  of  the  drainage-tube  free  in.the  abdominal  ca^dty.  The  peritoneum 
is  united  over  the  drain,  so  that  it  is  excluded  from  the  peritoneal  ca\dt3\ 

(8)  Removal  of  Glands. — If  infected  Ijmiph-giands  are  found  to  be  present,  it 
is  our  custom  to  finish  the  main  operation  up  to  the  point  of  closing  in  the 
peritoneum  before  dissecting  out  the  glands,  in  order  to  be  readj^  to  finish  the 
operation  quickly  if  the  patient  begins  to  show  signs  of  shock  or  if  serious  diffi- 
culty is  encountered  in  dissecting  out  the  glands.  The  removal  of  the  glands 
requires  patience  and  skill  on  the  part  of  the  operator. 


~^\cx^^er 


Fig.  404. — Wertheim's  Operatiox  for  Ca.nxeu  of  the  Cervix. 
Final  Step.     The  peritoneum  has  been  completely  sutured  over  the  rubber  drains.     Note  that  the 

four  middle  sutures  are  interrupted. 

Shock  depends  almost  exclusively  on  the  loss  of  blood.  In  the  average 
case  where  the  hemorrhage  has  not  been  severe,  there  is  no  shock  and  the 
convalescence  is  rapid. 

Comphcations  that  may  be  met  with  during  the  operation  are  injury  to  the 
bladder,  ureter,  or  rectum,  and  dangerous  uncontrolled  hemorrhages.  The  last 
are  most  apt  to  be  encountered  in  cases  where  there  has  been  a  long-standing 
pelvic  inflammatory  disease  with  peritoneal  adhesions.  In  these  cases  the  land- 
marks become  confused  and  the  usual  planes  of  cleavage  between  tissues  are 
lost.     The  same  is  true  in  operating  on  cases  that  have  been  treated  by  radium. 

EXTENDED  VAGINAL  HYSTERECTOMY  FOR  CANCER  OF  THE  CERVIX 

The  operation  developed  by  Schauta  is  a  very  difficult  one,  and  should  be 
attempted  only  by  those  familiar  with  the  vaginal  route  for  performing  pelvic 
surgery.     The  illustrations  of  this  operation  are  adapted  from  Schauta. 


HYSTERECTOMY    OPERATIONS 


745 


The  cancerous  area  is  first  thoroughly  cureted  and  cauterized.  The  opera- 
tion is  then  performed  by  the  following  steps: 

(1)  Circumcision  of  the  Lower  End  of  the  Vagina. — A  circular  incision  is 
made  around  the  circumference  of  the  vagina  at  the  introitus,  and  the  vaginal 
wall  dissected  away  for  the  distance  of  about  2  inches.  In  this  way  a  cuff  is 
formed  the  open  end  of  which  is  closely  sewed  with  interrupted  sutures,  the 
ends  of  which  are  left  long  and  included  in  a  clamp.     The  vaginal  cuff  is  now 


Fig.  405.- — Schauta's  Operation  for  Cancer 

OF  THE  Cervix. 

Initial  circumcision  of  the  vagina. 


Fig.  406. — Schauta's  Operation  for  Cancer 

OF  the  Cervix. 

The  vaginal  cuff  is  being  dissected. 


held  forward  by  the  sutures,  and  the  separation  of  the  vagina  continued  along 
its  lateral  and  posterior  wall,  care  being  taken  not  to  injure  the  rectum.  The 
dissection  of  the  vagina  from  the  rectum  should  be  carried  out  wdth  blunt  scis- 
sors rather  than  by  stripping  with  gauze. 

(2)  Paravaginal  Section. — When  the  vagina  has  been  well  freed  from  the 
rectum  a  deep  incision  is  made  in  the  left  lower  angle  of  the  vaginal  bed,  extend- 
ing first  laterally  to  the  lower  end  of  the  left  labium  minus,  then  turning  down- 
ward parallel  to  the  rectum  and  to  the  left  of  it,  separating  the  fibers  of  the 


746 


GYNECOLOGY 


M\i.^.^^iXVifcS- 


FiG.  407. — Schauta's  Operation  for  Cancer  op  the  Cervix. 

The  vaginal  cuff  has  been  dissected  out  and  closed  with  traction  sutures.      The  bladder  is  exposed. 

The  deep  paravaginal  incision  has  been  made  through  the  perineum. 


HYSTERECTOMY    OPERATIONS 


747 


levator  ani  muscle,  curving  around  the  anus,  and  terminating  posterior  to  it, 
near  the  median  line.  Deeper  in,  the  incision  splits  the  paravaginal  and  para- 
rectal tissues,  the  coccygeal  muscles,  and  the  cellular  tissue  of  the  ischiorectal 
fossa.  Much  bleeding  is  encountered,  which  can  be  controlled  by  ligature  and 
gauze  packing.  By  this  incision  a  surprisingly  large  amount  of  room  is  afforded 
for  carrying  out  the  other  steps  of  the  operation.     The  tissue  corresponding  to 


Fig.  408. — Schauta's  Operation  for  Cancer  of  the  Cervix. 

The  bladder  has  been  separated  from  its  vaginal  and  cervical  attachments  and  held  up  by  the 

upper  retractor.     The  uterine  artery,  ureter,  and  parametrium  of  the  left  side  are  exposed. 


Douglas'  fossa  is  now  picked  up  and  cut  and  the  recto-uterine  pouch  opened.  A 
large  strip  of  gauze  is  inserted  into  the  pouch  to  prevent  the  prolapse  of  the 
bowels. 

(3)  Separation  of  the  Bladder  and  Identification  of  the  Ureters. — The  vaginal 
wound  is  now  held  well  back  by  the  tension  on  the  attached  sutures,  and  the 
bladder  dissected  away  from  the  vagina  with  blunt  scissors.     The  dissection 


748 


GYNECOLOGY 


Fig.  409. — Schauta's  Operation  for  Cancer  of  the  Cervix. 

The  left  uterines  have  been  tied  and  cut.     The  ureter  becomes  freed.     With  the  guidance  of  the  left 

forefinger  the  parametrium  is  being  divided. 

should  be  carried  well  out  on  the  sides  of  the  vagina  until  the  ureters  are  exposed. 
The  bladder  is  now  retracted  upward  and  an  opening  made  into  the  uterovesical 
Douch. 


HYSTERECTOMY    OPERATIONS 


749 


(4)  Ligature  of  the  Uterines. — The  vagina  is  held  sharply  over  to  the  right 
side,  while  the  operator  identifies  the  uterine  artery  with  his  left  forefinger. 
A  hgature-carrier  is  passed  through  the  base  of  the  broad  hgament  around 
the  uterine  vessels.  The  Hgature  is  tied  and  the  uterus  cut  from  the  part  of 
the  ligament  secured  by  the  tie.  The  vessels  of  the  opposite  side  are  tied  in 
the  same  way. 


Fig.  410. — Schauta's  Operation  for  Cancer  of  the  Cervix. 
The  fundus  of  the  uterus  has  been  delivered.     The  broad  ligament  of  the  left  side  is  about  to  be  tied 

and  cut. 


The  parametrial  tissue  is  excised  as  far  away  from  the  uterus  as  possible, 
there  being  some  bleeding  from  the  hemorrhoidal  vessels  that  run  to  the 
uterosacral  ligaments. 

(5)  Removal  of  Uterus  and  Adnexa. — The  fundus  of  the  uterus  is  delivered 
through  the  opening  into  the  uterovesical  pouch.  This  is  accomplished 
by  passing  the  forefinger  of  the  left  hand  into  the  pouch  of  Douglas  and 
anteflexing  the  fundus  by  pressure  from  behind.  The  fundus  is  seized  with 
strong  volsella  and  drawn  sharply  forward.     In  this  way  the  broad  Hgaments 


750 


GYNECOLOGY 


are  brought  into  view.  The  uterus  is  then  drawn  to  the  right,  and  with 
the  left  forefinger  as  a  guide  a  double  ligature  is  applied  on  a  ligature-carrier 
to  the  broad  ligament.  The  round  and  infundibulopelvic  ligaments  are  tied 
and  the  uterus  severed  from  the  broad  ligament.  The  same  procedure  is  carried 
out  on  the  opposite  side  and  the  uterine  mass  removed. 


Fig.  411. — Schauta's  Operation  For  Cancer  of  the  Cervix. 
Closing  the  peritoneal  layer  by  a  continuous  stitch. 

The  paravaginal  wound  is  closed  with  deep  sutures-.  The  peritoneum  is 
closed  and  a  gauze  packing  left  in  the  opening  above  the  vaginal  wound. 

The  convalescence  is  a  long  one  owing  to  the  time  taken  for  healing  of  the 
vaginal  wound. 

MYOMECTOMY  OPERATIONS 


ABDOMINAL  MYOMECTOMY 


In  performing  the  operation  for  enucleation  of  uterine  myomata  the  ab- 
dominal incision  must  be  made  sufficiently  large  to  admit  of  convenient  handling 
of  the  pelvic  organs.      The  fundus  of  the  uterus  is  seized  with  double  hooks 


MYOMECTOMY   OPERATIONS 


751 


and  drawn  toward  the  abdominal  wound  into  such  a  position  as  will  expose  best 
the  myoma  to  be  removed.  It  is  often  advantageous  to  insert  a  second  pair  of 
double  hooks  into  the  uterine  wall  immediately  below  the  lower  pole  of  the 
tumor,  traction  on  which  lifts  the  uterus  so  that  the  field  of  operation  is  more 
in  a  horizontal  plane.  An  incision  through  the  wall  of  the  uterus  is  made 
parallel  with  the  axis  of  the  uterus  over  the  most  prominent  part  of  the  tumor. 
The  incision  is  carried  down  to  the  surface  of  the  myoma,  which  can  usually  be 


>N?P.(ix'(x\>e-S 


Fig.  412. — Abdominal' Myomectomy. 
Incision  for  a  myoma  in  the  posterior  uterine  wall. 


recognized  by  the  difference  in  direction  of  its  fibers  from  those  of  the  uterine 
wall.  When  the  surface  of  the  myoma  has  been  exposed  the  tumor  is  grasped 
with  a  pair  of  double  hooks  carried  deeply  into  the  tissue.  With  firm  traction 
on  the  double  hooks  the  tumor  can  then  be  readily  shelled  out  by  means  of 
some  blunt  dissecting  instrument,  a  pair  of  blunt-tipped  curved  scissors  being 
especially  useful.  The  enucleation  is  done  carefully  to  prevent  too  great  lacera- 
tion of  the  tissue  of  the  uterine  wall  and  to  avoid,  if  possible,  opening  the  uterine 
cavity. 


752 


GYNECOLOGY 


If  the  tumor  happens  to  be  an  adenomyoma  it  cannot  be  shelled  out  in  this 
way,  growing  as  it  does  diffusely  in  the  wall  of  the  uterus.  Under  these  circum- 
stances the  tumor  must  be  dissected  away  from  the  uterine  tissue,  from  which 
it  cannot  always  be  clearly  differentiated. 

When  the  myoma  has  been  removed,  there  is,  except  in  the  case  of  small 
trnnors,  considerable  bleeding  from  the  bed  in  which  it  lay.  The  careful  con- 
trol of  this  hemorrhage  is  of  supreme  importance,  for  it  is  to  the  lack  of  this 
precaution  that  the  notoriously  bad  after-results  of  myomectomy  are  chiefly 
due.     Bleeding  points  should  be  isolated  and  ligatured  as  far  as  possible,  and 


bteif'i.'nQ:, 


\y(."^Gr<N\J«.S 


Fig.  413. — Abdominal  Myomectomy. 
The  myoma  is  being  shelled  out  from,  its  bed  by  blunt  dissection. 


where  this  cannot  be  done,  carefully  placed  mass  sutures  must  be  applied. 
Buried  sutures  are  also  used  to  close  in  the  dead  space  left  by  the  removal  of 
the  tumor,  to  avoid  the  retention  of  blood-clots  in  the  uterine  wall,  and  the 
peculiarly  disturbing  constitutional  symptoms  which  the  disintegration  of  the 
clots  seems  to  produce.  The  peritoneum  is  closed  by  deep  figure-of-8  cat- 
gut stitches  (Fig.  414),  this  form  of  stitch  being  especially  valuable  both 
because  of  its  broad  approximation  of  tissues  and  because  by  its  use  fewer  knots 
are  exposed  on  the  surface  of  the  uterus. 

The  enucleation  of  large  intramural  myomata  is  a  bloody  operation,  and 


MYOMECBOMY   OPERATIONS 


753 


results  in  great  mutilation  of  the  uterine  body.  It  should  not  be  undertaken 
except  under  extraordinary  circumstances.  Pedunculated  myomata,  on  the 
other  hand,  even  of  very  large  size,  may  be  removed  without  danger. 

When  it  is  necessary  to  remove  a  considerable  number  of  small  myomata  it 
is  important  when  possible  to  make  incisions  in  the  uterine  wall  in  such  a  way 
that  more  than  one  tumor  may  be  extracted  through  the  same  incision.  This 
is  advantageous  because  it  makes  fewer  wounds  in  the  uterine  wall  along  wjiich 
postoperative  adhesions  may  form. 


Nvll^t^-aues- 


Fig.  414. — Abdominal  Myomectomy. 
The  wound  in  the  uterine  wall  is  being  closed  with  figure-of-8  sutures  deepl.v  placed. 

After  a  myomectomy  operation  it  is  always  advisable  to  suspend  the  uterus 
in  some  appropriate  way  in  order  to  prevent  the  possibility  of  an  adherent  retro- 
version, a  complication  which  otherwise  is  extremely  hkely  to  occur. 

Omental  Grafting.— After  myomectomy  operations  involving  the  posterior 
wall  of  the  uterus  adhesions  are  extremely  liable  to  form  along  the  hne  or  lines  of 
incision.  This  comphcation  may,  to  a  certain  extent,  be  prevented  by  attaching 
an  omental  graft  to  the  uterine  wall.     The  omentum  is  drawn  out  of  the  ab- 

48 


754 


GYNECaLOGY 


_,y^ 


^. 


\ 


/ 


Fig.  415. — Omental  Grafting. 

The  omentum  is  lifted  from  the  abdominal  wound  and  a  wedge-shaped  section  removed  at  a  point 

where  the  omentum  is  plentifully  supplied  with  blood-vessels. 


J 

^    ''^ 

H      '^ 

. 

Wa 

^ 

vi-"" 

"^  .?"-&;-> 

Fig.  416. — Omental  Graft. 
The  triangular  piece  of  omentum  has  been  attached  to  the  posterior  wail  of  the  uterus  by  several 

catgut  sutures. 


dominal  wound  and  inspected  as  in  Fig.  415.     A  portion  having  been  selected 
which  contains  a  good  blood-supply,  a  wedge-shaped  piece  is  exsected  of  a  size 


MYOMECTOMY    OPERATIONS 


755 


sufficient  to  cover  the  area  on  the  surface  of  the  uterus  requiring  protection. 
The  cut  edges  of  the  omentum  are  sewed  together  after. ligature  of  the  bleeding 


Jvl\iomtV 


Fig.  417. — Vaginal  Myomectomy. 
Clamping  the  pedicle. 


vessels.    The  omental  graft  is  then  applied  to  the  uterus  and  stitched  in  place  by 
a  few  interrupted  sutures  of  fine  catgut  as  in  Fig.  416. 


756  GYNECOLOGY 

VAGINAL  MYOMECTOMY 

By  vaginal  myomectomy  is  meant  the  removal  of  pedunculated  submucous 
myomata  through  the  vagina,  and  not,  as  it  is  used  in  some  books,  the  enuclea- 
tion of  intramm'al  and  subperitoneal  tumors  by  vaginal  section,  a  procedure 
which  is  not  recommended  by  the  present  writer. 

Pedunculated  submucous  mj^omata  first  make  themselves  e\ddent  by  bleed- 
ing or  by  a  foul  discharge,  or  by  both.  They  are  usually  necrotic  and  septic. 
If  they  are  associated  with  intramural  and  subserous  fibroids,  as  they  commonly 
are,  it  is  best  to  remove  the  submucous  tumor  first,  and  to  perform  the  radical 
operation  for  extirpation  of  the  uterus  at  a  later  date.  Otherwise  there  is 
much  danger  of  sepsis. 

In  removing  a  polypoid  myoma  the  patient  is  in  the  perineal  position  and, 
preferably,  under  full  anesthesia.  Unless  there  is  some  constitutional  contra- 
indication, full  anesthesia  is  advisable  because  of  the  possibiUty  of  a  smart  hem- 
orrhage. 

In  performing  the  operation  the  pedicle  of  the  tumor  is  first  sought  with  the 
finger.  If  the  attachment  is  high  up  in  the  uterus  it  must  be  found  with  a  blunt 
instrument  like  a  pair  of  uterine  scissors.  When  the  pedicle  is  found,  it  is 
enclosed  and  crushed  in  the  end  of  a  uterine  clamp.  If  the  tumor  is  thoroughly 
necrotic  the  clamping  will  often  cause  it  to  fall  away  from  the  attachment,  and 
the  clamp  can  be  removed  T\'ithout  bleeding.  If  the  tumor  is  not  attached  too 
far  up  in  the  canal  it  may  often,  if  necrotic,  be  easily  detached  by  the  end  of  the 
finger  without  serious  bleeding.  If,  however,  the  pedicle  is  firm,  it  must  be  cut 
with  scissors,  which  are  guided  in  their  direction  by  the  clamp  attached  to  the 
pedicle. 

Removal  of  the  clamp  does  not  often  cause  more  than  moderate  bleeding. 
Sometimes,  however,  the  hemorrhage  is  sufficient  to  require  packing  the  uterine 
canah  with  gauze.     The  packing  is  removed  on  the  following  day. 

Patients  from  whom  a  necrotic  myomatous  polj^p  has  been  removed  usually 
run  a  septic  temperature  for  several  days  after  the  operation,  with  a  moderate 
leukocjrtosis.  It  is  this  condition  which  serves  as  a  warning  not  to  perform  a 
radical  operation  on  the  uterus  in  the  presence  of  one  of  these  sloughing  tumors. 


OPERATIONS   ON  THE  TUBES 


SALPINGO-OOPHORECTOMY 


When  the  tube  and  ovary  are  to  be  removed  together  it  is  essential  to 
determine  first  whether  there  has  been  an '  inflammatory  process  in  the  tube. 
If  there  are  no  signs  of  previous  infection,  the  tube  may  be  amputated  near 
the  uterus,  with  a  short  pedicle,  without  danger  of  future  trouble.  If,  however, 
there  are  indications  of  salpingitis,  whether  recent  or  long  standing,  the  entire 
tube  should  be  exsected  from  the  cornu  of  the  uterus. 

In  dealing  with  an  ovarian  cyst  with  a  free  pedicle  a  convenient  technic  is 
as  follows:  The  torsion,  if  present,  is  first  reduced,  so  that  the  broad  hgament 
pedicle,  which  was  twisted  into  a  rope  form,  is  smoothed  out  and  flat.     Two 


Fig.  418. — ^Salpingo-oophorectomy. 
Showing  method  of  clamping  and  cutting  the  broad-ligament  pedicle  of  an  ovarian  cyst. 

clamps  are  then  applied,  meeting  each  other  at  an  angle  near  the  base  of  the 
broad  ligament.  One  clamp  near  the  uterus  includes  the  tube  and  ovarian 
ligament,  while  the  other  includes  the  infundibulopelvic  ligament,  which  con- 
tains the  ovarian  vessels.  The  tumor  mass  over  which  the  tube  is  usually  spread 
is  then  removed  by  cutting  the  broad  ligament  pedicle  in  a  V  shape,  and  in  such 
a  manner  as  to  leave  a  margin  of  tissue  beyond  the  clamps.  If  the  tumor 
possesses  a  large  blood-supply,  the  spilhng  of  reflux  blood  from  the  tumor  can 
be  avoided  by  placing  distal  clamps  and  cutting  between  the  two  sets  of  clamps. 
This  prevents  soiling  the  field  of  operation. 

When  the  tumor  has  been  removed  the  two  clamps  on  the  stump  of  the  broad 
ligament  are  shifted  to  the  corners,  an  assistant  clamping  the  ends  of  the  three 

757 


758 


GYNECOLOGY 


or  four  vessels  that  bleed  from  the  cut  edge.  The  tube  and  vessels  are  then 
tied  separately,  two  ligatures  being  applied  to  the  ovarian  vessels.  The  two 
clamps  which  are  attached  to  the  ends  of  the  V-shaped  pedicle  are  approxi- 
mated, and  the  wound  edges  very  carefully  united  with  a  continuous  No.  0  catgut 
stitch  beginning  at  the  apex  of  the  V.  It  is  possible  in  this  way  to  close  the 
wound  with  a  minimmii  exposure  of  raw  edge,  a  matter  of  very  great  importance 
in  the  avoidance  of  future  pelvic  adhesions.  Special  care  must  be  taken  when 
completing  the  suture  in  uniting  the  stump  of  the  tube  to  the  stump  of  the 
infundibulopelvic  ligament  not  to  leave  a  clumsy  mass  of  tissue  and  knots. 
If  for  any  reason  this  is  unavoidable,  the  round  ligament  can  be  drawn  over  the 
mass  and  stitched  so  as  to  prevent  its  exposure  and  possible  adherence  to  the 
intestines. 


} 


i.n"S\jn?)\\)u\oPe\\)\o  Lii.oax\-\ex\ 


Fig.  419. — Salpingo-oophokectomt. 
Closure  of  the  wound  in  the  broad  ligament  by  approximating  the  stump  of  the  infundibulopelvic 

ligament  to  the  stump  of  the  tube. 


After  performing  a  salpingo-oophorectomy  the  uterus  should  always  be 
suspended  by  a  round  hgament  operation,  even  if  its  position  at  the  time  of 
operation  is  perfectly  good,  for  if  this  is  not  done  a  later  retroversion  is  almost 
inevitable. 

SALPINGECTOMY 

Exsection  of  the  tube  without  removal  of  the  ovarj^  is  an  operation  used  in 
the  conservative  surgery  of  pelvic  inflammation.  Where  this  operation  is  done 
it  is  not  enough  to  amputate  the  tube  at  the  uterine  cornu;  it  must  include  a 
resection  of  the  interstitial  portion  of  the  tube  to  prevent  the  possibility  of  a 
later  exacerbation  of  the  disease  in  the  tubal  isthmus. 

In  order  to  hold  the  tube  in  position  for  easy  dissection  the  edge  of  the  meso- 
salpinx between  the  fimbriated  extremity  and  the  ovary  is  seized  by  a  clamp 
or  pressure  forceps.     Another  clamp,  preferably  with  teeth,  is  apphed  to  the 


OPERATIONS    ON    THE    TUBES 


759 


tissue  of  the  uterine  fundus  beyond  the  tubal  isthmus.  The  tube  is  then  re- 
moved b}"  cutting  through  the  mesosalpinx,  avoiding  as  much  as  possible  the 
veins  of  the  broad  ligament.  A  few  bleeding  points  require  hgature.  When 
the  dissection  has  reached  the  uterus  the  remaining  portion  of  the  tube  is  re- 
moved with  a  knife  by  cutting  a  deep  wedge-shaped  piece  of  uterine  tissue  from 
the  cornu.  In  this  way  the  entire  tube,  including  its  isthmus,  is  exsected.  When 
the  incision  is  made  into  the  uterus  a  spurting  vessel  is  alwaj^s  encountered.  It 
is  important  to  tie  this  vessel  in  such  a  way  as  not  to  distort  the  tissue  or  expose 
too  much  catgut. 


/  "7 


.  '/f 


Fig.  420. — SALPixGECTOinr. 
Sho^-ing  the  method  of  completeh-  removing  the  tube,  including  the  isthmus,  which  is  apt  to  be  im- 
plicated  in   the  infiammatorj'   process    (salpingitis  isthmica   nodosa). 


The  success  of  the  operation  depends  to  a  great  extent  on  the  manner  of 
sewing  up  the  wound,  which  must  be  done  so  as  to  leave  as  smooth  a  peritoneal 
surface  as  possible  and  to  avoid  the  exposure  of  catgut  knots. 

A  convenient  method  of  closing  the  wound  is  to  begin  at  the  uterine  end 
and  first  place  deep  into  the  uterine  wall  a  figure-of-8  stitch  of  No.  1  catgut. 
This  closes  the  wedge-shaped  opening  in  the  cornu.  It  can  be  made  to  include 
the  spurting  vessel  alluded  to  above.  The  peritoneal  edges  of  the  mesosalpinx 
are  now  united  with  a  continuous  fine  catgut  stitch.  By  using  the  Lembert 
method  of  applying  the  stitch  the  eversion  of  raw  edges  may  be  avoided,  and  the 
catgut  knots  on  the  vessels  can  be  covered  in.  If,  however,  as  is  often  the  case, 
there  have  been  manj'  adhesions,  the  mesosalpinx  wound  is  ragged  and  the 


760 


GYNECOLOGY 


peritoneal  surfaces  damaged.     In  such  a  case  it  is  impossible,  even  with  the 
most  painstaking  care,  to  leave  a  wound  which  can  be  insured  against  the  for- 


I 


^M/^ 


Fig.  421.— Salpingectomy. 
The  tube  of  the  left  side  has  been  exsected,  including  the  isthmus,  and  the  wound  in  the  peritoneum 

closed  by  a  running  suture. 

mation  of  postoperative  adhesions.     It  is  for  this  reason  chiefly  that  conserva- 
tive surger}^  for  pelvic  inflammatory  disease  so  often  results  in  failure. 


SALPINGOSTOMY  fSTOMATOPLASTIC) 

As  stated  above,  when  it  is  necessary  to  remove  a  tube  that  has  been  dam- 
aged by  infection,  it  is  not  good  surgery  to  leave  any  part  of  it,  on  account  of  the 
danger  of  a  later  recurrent  inflammatory  process  in  the  remaining  stump.  It 
is  necessary,  however,  sometimes  to  take  this  risk  when  the  desire  for  children 
surmounts  all  other  considerations.  The  chances  of  impregnation  through  a 
damaged  and  resected  tube  are,  to  be  sure,  not  very  promising,  yet  the  possi- 
bility is  present,  and,  according  to  the  author's  figures,  is  somewhat  greater 
than  is  ordinarily  supposed. 

In  deciding  on  a  stomatoplastic  operation  on  the  tube  the  pelvic  organs  must 
first  be  thoroughly  freed  of  adhesions  and  the  tubes  and  ovaries  carefully  in- 
spected. Only  those  organs  are  chosen  for  preservation  which  offer  a  reasonable 
chance  of  regaining  proper  function.  Thus,  a  tube  which  shows  a  salpingitis 
nodosa  at  the  cornu  is  entirely  hopeless  and  should  be  removed  completely. 


OPERATIONS    ON    THE    TUBES  761 

A  tubo-ovarian  mass  in  which  there  is  much  destruction  of  the  ovarian  tissue, 
such  as  results  from  combined  abscess  or  cyst  of  the  two  organs,  must  also  be 
removed  entire. 

A  tube  which  is  closed  and  adherent  at  the  fimbriated  extremity,  but  without 
thickening  of  the  wall  or  occlusion  of  the  proximal  part  of  the  canal,  even  if  it 
is  somewhat  distended  (hydrosalpinx),  is  suitable  for  resection.  The  presence 
of  one  good  ovary  is,  of  course,  essential,  but  the  ovary  may  be  on  the  opposite 
side  from  the  tube  to  be  repaired,  for  it  has  been  shown  that  impregnation  can 
take  place  as  the  result  of  migration  of  the  ovum  across  the  pelvis. 

In  case  one  or  both  ovaries  are  good,  but  both  tubes  are  impossible,  the  only 
chance  for  pregnancy  is  by  transplantation  of  ovarian  tissue  in  the  uterine 
cornua. 

To  perform  the  operation  of  salpingostomy  the  tube  is  held  up  to  view  by 
attaching  a  clamp  to  the  edge  of  the  mesosalpinx.     The  tube  is  then  trimmed 


Fig.  422.^ — Salpingostomy. 

Showang  the  method  of  creating  a  new  ostium  for  a  tube  closed  by,  inflammation.     This  operation  is 

performed  only  for  the  purpose  of  restoring  fertility. 

away  from  the  ovary  up  to  a  point  where  the  tubal  wall  begins  to  have  a  normal 
look,  usually  about  a  third  to  a  half  of  the  length  of  the  tube  from  its  extremity. 
Bleeding  points  are  tied  with  fine  catgut.  The  mesosalpinx  is  grasped  with 
fine  pressure  forceps  close  to  the  tube  at  the  point  where  it  is  to  be  amputated. 
It  is  important  not  to  crush  the  tube  at  any  time  with  clamps  or  forceps.  The 
tube  is  then  cleanly  amputated,  and  a  probe  passed  gently  into  the  canal  to 
determine  whether  or  not  it  is  patent.  This  can  be  done  for  only  a  short  distance, 
for  it  is  impossible  to  determine  the  patency  of  the  tube  near  the  uterus  even 
under  normal  conditions,  it  being  too  small  to  admit  a  fine  probe  without  danger 
of  injuring  the  tubal  mucous  membrane.  The  question  of  patency  in  this  part 
of  the  tube  must,  therefore,  be  guessed  at  from  its  generak appearance. 
'    The  tube  is  then  slit  up  a  short  distance  in  order  to  make  the  new  ostium 


762  GYNECOLOGY 

wider.  The  mucous  membrane  of  the  tube  is  next  united  to  the  peritoneal 
covering  with  sutures  of  No.  00  catgut  passed  in  a  very  fine  needle.  It  is  im- 
portant to  accomplish  this  with  as  few  stitches  as  possible,  for  the  catgut  knots 
are  especially  Hable  to  promote  adhesions.  It  is  usually  necessary  to  use  only 
three  sutures,  as  seen  in  Fig.  422. 

Another  method  for  performing  a  stomatoplastic  operation  on  the  tube  is  that 
proposed  by  Bell  and  illustrated  by  Fig.  423.  This  operation  is  applicable 
where  there  has  been  a  closure  of  the  fimbriated  end  without  serious  damage  to 


Fig.  423. — Bell's  Salpingostomy. 

A  longitudinal  incision  is  made  in  the  closed  and  dilated  end  of  the  tube.     The  perineum   and 

mucous  membrane  of  the  tube  are  united  with  a  hemstitch  suture. 

the  tubal  wall  or  closure  of  its  lumen.  A  long  longitudinal  incision  is  made  near 
the  end  of  the  tube.  The  edges  of  the  wound  are  whipped  over  with  a  hemstitch 
of  fine  catgut. 

OPERATION  FOR  TUBAL  STERILIZATION 

It  is  occasionally  important  to  sterilize  a  patient  without  the  removal  of 
any  of  the  organs.  Simple  tying  of  the  tubes  is  quite  inadequate,  as  the  lumen 
of  the  tube  becomes  readily  re-estabhshed.  The  same  is  true  of  section  of  the 
tube  and  hgature  of  the  cut  ends.  Among  the  numerous  methods  recom- 
mended for  tubal  sterihzation  we  have  adopted  that  of  Taussig,  who  describes 
his  operation  as  follows: 

"The  abdomen  is  opened  by  a  small  median  incision  in  the  usual  manner, 
and  the  uterine  end  of  one  Fallopian  tube  seized  with  forceps.  The  uterus  is 
thus  pulled  into  view,  so  that  a  suture  can  be  passed  through  the  uterine  horn 
at  the  tubal  insertion.      Before  tying  this  suture  the  interstitial  portion  of 


OPERATIONS    ON    THE    TUBES  763 

the  tube  is  cut  away  by  a  V-shaped  incision.  Next,  the  tube  is  freed  from  its 
peritoneal  attachment  for  a  -chstance  of  about  1  inch,  and,  a  hgature  having 
been  thrown  around  the  distal  end,  this  free  portion  of  the  tube  is  resected, 

"With  an  arterj^  forceps  or  Mayo  dissecting  scissors  the  laj-ers  of  the  broad 
ligament  are  separated  from  each  other  at  the  point  where  it  has  been  opened  up. 
Catching  the  end  of  the  tube  with  an  extra  suture,  to  prevent  it  from  slipping, 
the  threaded  needle  is  now  passed  through  the  open  space  in  the  broad  hgament, 
and  emerges  just  anterior  to  the  round  ligament,  near  the  attachment  of  the 
vesical  peritoneum  to  the  uterus.  An  extra  suture  is  passed  through  the  peri- 
toneum at  this  point  so  as  to  completely  burj^  this  end  of  the  Fallopian  tube  in 
the  broad  ligament. 

"The  third  step  in  the  operation  consists  of  sewing  the  round  ligament  by 
one  or  more  sutures  to  the  upper  posterior  surface  of  the  uterus,  thus  closing 
over  the  point  of  the  tubal  insertion  and  the  small  open  space  in  the  peritoneum 
of  the  broad  ligament. 

'The  same  technieis  observed  in  resecting  the  tube  of  the  other  side,  and  the 
abdomen  closed  in  the  usual  manner." 


OPERATIONS   ON  THE   OVARIES 


RESECTION  OF  THE  OVARY 


This  operation  does  not  at  present  hold  the  prominent  place  in  gynecologic 
surgery  that  it  did  in  the  days  before  it  was  learned  that  the  so-called  cystic 
degeneration  of  the  ovaries  is,  for  the  most  part,  a  physiologic  process.  There 
are  times,  however,  when  the  process  passes  the  physiologic  bounds  and  the 
operation  of  resection  must  be  resorted  to.  This  is  especially  true  when  one 
follicle  seems  to  be  growing  at  the  expense  of  the  rest  of  the  ovarian  tissue,  and 
gives  pro iTiise  of  becoming  a  large  retention  cyst.     The  necessity  of  performing 


J''i(;.  424. — Resection  of  Ovary. 

A  follicle  cyst  is  being  exsected.     The  clamps  which  hold  the  ovary  into  view  are  lightly  placed  so  as 

not  to  crush  the  tissues  which  they  include. 


a  resection  of  the  ovary  in  the  course  of  a  pelvic  operation  must,  however,  always 
be  regarded  as  a  regretable  incident,  for  the  likelihood  of  the  ovary's  becoming 
adherent  is  very  great. 

The  ovary  is  exposed  to  view  by  placing  one  clamp  on  the  edge  of  the  meso- 
salpinx and  the  other  on  the  ovarian  suspensory  ligament,  the  clamps  being 
locked  just  tight  enough  to  hold  the  ovary  in  place,  but  not  so  as  to  crush  the 
tissue  or  shut  off  the  blood-supply.  An  oval  incision  is  then  made  around 
the  cyst,  exposing  the  translucent  capsule  of  the  cyst,  which  can  easily  be 
shelled  out  of  its  bed  in  the  ovarian  tissue.  If  the  supporting  clarrips  have  not 
been  apphed  too  tightly  there  is  some  bleeding  from  the  hilum  of  the  ovary. 

764 


OPERATIONS    ON   THE    OVARIES 


765 


All  the  bleeding  should  be  very  carefullj^  stopped  by  fine  catgut  ligation.  When 
the  bleeding  seems  to  be  stopped  the  clamps  should  be  unlocked,  to  be  sure  that 
they  are  not  accidentally  controlling  other  small  vessels.  The  wound  in  the 
ovary  is  then  sewed  with  fine  catgut  on  a  small  curved, needle.  The  ovarian 
tissue  is  very  friable,  especially  if  the  operation  is  near  a  corpus  luteum.  The 
edges  should  be  trimmed  until  firm  tissue  is  reached,  care  being  taken  that  the 


Fig.  42o, — Resection  of  Ovary. 
The  cyst  has  been  dissected  out  of  its  bed  and  the  wound  of  the  ovary  sewed  with  a  fine  catgut 

running  stitch. 

edges  when  approximated  will  give  good  coaptation  without  tension  and  without 
presenting  ragged  edges.  The  greatest  care  should  be  taken  in  sewing  the  wound 
so  as  to  leave  it  as  smooth  as  possible,  in  order  to  safeguard  against  adhesions. 


TRANSPLANTATION  OF  OVARIAN  TISSUE 

Transplantation  of  ovarian  tissue  is  principally  employed  either  for  restora- 
tion of  fertility  after  a  pelvic  inflammation,  or  for  the  purpose  of  relieving  the 
vasomotor  symptoms  of  the  artificial  menopause  following  hysterectomy. 

In  the  first  instance  the  operation  is  indicated  when  it  is  necessary  to  remove 
both  tubes,  one  or  both  ovaries  being  normal.  The  steps  of  the  operation  are 
as  follows : 

The  tube  of  one  side  is  completely  exsected  in  the  manner  described  for  sal- 
pingectomy. The  wound  of  the  mesosalpinx  is  carefully  closed  with  the  ex- 
ception of  the  wedge-shaped  opening  made  in  the  cornu  of  the  uterus  in  dis- 
secting out  the  isthmus  of  the  tube.  This  small  cavity  is  now  examined  to 
make  sure  that  all  scar-  and  inflammatory  tissue  have  been  removed.  A  probe 
determines  whether  there  is  free  communication  with  the  uterine  canal,  though 
the  opening  should  be  small.      A  slice  of  tissue  about  \  inch  thick  and  the  size 


766 


GYNECOLOGY 


of  the  thumb-nail  is  taken  from  the  ovary,  including  epithelial  covering,  cor- 
tex, and  medullary  layer,  and  placed  in  the  opening  in  the  uterine  cornu,  the 
wound  being  closed  with  a  figure-of-8  stitch.  The  wound  in  the  ovary  is 
sewed  by  a  running  stitch  of  fine  catgut.  The  same  process  is  repeated  on 
the  other  side.  If  only  one  ovary  has  been  left,  enough  tissue  must  be  taken 
to  supply  both  cornua. 

The  operation  of  transplantation  after  hysterectomy  is  as  follows:  A  small 
receptacle  containing  warm  sterile  salt  solution  is  ready  at  hand.  When  the 
uterus  and  adnexa  are  removed  from  the  pelvis  the  surgeon  immediately  cuts 
off  one  of  the  ovaries  and  places  it  in  the  warm  salt  solution,  where  it  is  kept 


Fig.  426.- — Transplantation  of  Ovarian  Tissue  in  the  Horns  of  the  Uterus. 
The  tubes  have  been  exsected.     Wedges  have  been  removed  from  the  ovaries  and  the  wounds 
closed.     A  section  of  ovarian  tissue  is  being  introduced  in  the  right  cornu.     The  same  procedure  has 
been  carried  out  and  completed  on  the  left  side. 


until  the  operator  is  ready  to  implant  it.  Numerous  locations  are  used  for  the 
implantation,  most  commonly  between  the  leaves  of  the  broad  ligament  and  in 
the  abdominal  wall.  Of  these  two  sites,  the  latter  is  far  preferable,  partly  because 
the  blood-supply  is  more  favorable  for  the  graft  and  partly  because  it  is  more 
accessible  if  by  chance  the  tissue  later  becomes  cystic  or  gives  trouble  otherwise. 
If  the  abdominal  wall  has  been  chosen  as  the  site  of  implantation  the  opera- 
tion is  completed  as  far  as  the  closure  of  the  abdominal  fascia.  A  place  is  then 
chosen  where  the  sheath  surrounds  the  edge  of  one  of  the  recti  muscles.  A  small 
slit  is  made  in  the  sheath  at  the  muscle  border.  The  ovary  is  taken  from  the 
salt  solution  and  a  slice  removed  from  the  healthiest  part,  including,  if  possible, 


OPERATIONS    ON    THE    OVARIES 


7Q7 


epithelium,  cortex,  and  medullary  tissue.  The  piece  of,  ovary  is  now  slipped 
into  the  small  opening  in  the  muscle  sheath  (Fig.  427),  and  placed  so  that  it  lies 
between  muscle  and  fascia.  The  opening  in  the  fascia  is  closed  with  one  suture 
of  fine  catgut. 


Fig.  427. — Implantation  of  Ovarian  Tissue  in  Abdominal  Wall. 
A  slice  from  the  ovary  is  being  inserted  between  the  fascia  and  right  rectus  muscle. 


It  is  important  to  remember  that  the  whole  organ  should  not  be  implanted 
in  the  abdominal  wall,  for  it  is  almost  sure  to  give  later  trouble  by  cystic  degenera- 
tion. By  using  a  sHce  of  the  ovary  the  establishment  of  a  new  circulation  in  the 
graft  is  more  surely  accomplished  than  if  the  intact  ovary  is  implanted. 


OPERATIONS   ON  THE  ABDOMINAL  WALL 

BAKDENHEUER'S  INCISION 

An  extended  transverse  incision  for  difficult  pelvic  operations  is  used  fre- 
quently abroad,  but  very  little  in  this  country.  This  incision  is  carried  with 
a  moderate  downward  curve  from  one  anterior  superior  spine  to  the  other. 
The  incision  is  made  transversely  through  the  entire  wall,  including  skin,  fascia, 
muscle,  and  peritoneum.  As  a  rule,  only  the  recti  are  divided,  but  if  the  opera- 
tion demands  it  the  lateral  muscles  of  the  abdomen  may  also  be  cut. 


Fig.  428. — Transverse  Incisioxs  for  Pelvic  Operations. 
The  shorter  of  the  two  red  lines  indicates  the  Pfannenstiel  incision.     The  longer  red  line  shows 
the  Bardenheuer  incision,  sometimes  used  for  extensive  pelvic  operations.    The  Pfannenstiel  incision 
cuts  only  the  skin  and  fascia  transversely.     The  Bardenheuer  incision  cuts  transversely  all  the 
layers  of  the  abdominal  wall  from  spine  to  spine. 


This  incision  gives  a  great  amount  of  room  for  manipulations  in  the  pelvis 
(Fig.  428).  Bardenheuer,  who  first  advocated  it,  recommends  also  turning 
down  the  upper  flap  of  peritoneum  and  suturing  it  to  the  posterior  pelvic  perito- 
neum in  order  to  protect  the  intestines  from  the  field  of  operation. 

This  incision  is  somewhat  too  radical  except  for  extraordinary  cases. 

768 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


769 


THE  PFANNENSTIEL  INCISION 

The  transverse,  or  Pfannenstiel,  incision  for  pelvic  operations  has  many 
adherents,  especially  abroad,  its  chief  value  being  based  on  cosmetic  considera- 
tions. The  use  of  this  incision,  the  scar  of  which  is  entirely  concealed  by  the 
pubic  hair,  obviates  the  ugly  appearances  so  frequently  seen  after  the  median 
longitudinal  cut,  such  as  keloid  formation,  pigmentation,  depression,  and 
spreading  of  the  scar.     The  technic  of  the  operation  is  as  follows: 


Fig.  429. — The  Pfannenstiel  Incision. 

The  skin  and  fat  hav«  been  incised  just  within  the  boundary  of  the  pubic  hair.     The  fascia  is  cut 

transversely  as  in  the  drawing  (after  D  oderlein-Kronig)..   , 


A  straight  or  slightly  curved  transverse  incision  3j  inches  in  length  is  made 
above  the  pubes  just  within  the  line  of  pubic  hair.  The  incision  is  carried  down 
through  skin,  fat,  and  fascia  to  the  rectus  muscles.  The  adhesion  of  the  fascia 
to  the  linea  alba  is  then  cut  away  with  scissors  from  the  upper  and  lower  fascial 
flaps  (Fig.  430).  The  recti  muscles  are  separated  by  blunt  dissection,  as  in  the 
median  incision,  and  the  peritoneum  is  cut  longitudinally.  The  simple  incision 
does  not  give  as  good  exposure  of  the  pelvis  as  does  the  median  incision,  nor  can 
the  appendix  and  other  portions  of  the  abdomen  be  as  easily  reached  and  ex- 
plored. If,  however,  the  ends  of  the  skin  and  fascia  wound  are  curved  upward, 
the  recti  muscles  may  be  drawn  more  widely  apart  and  a  much  better  exposure 

49 


770 


GYNECOLOGY 


is  afforded.  This  extension  of  the  wound  is  quite  necessary  in  the  performance 
of  the  more  difficult  pelvic  operations,  such  as  for  myoma,  pelvic  inflammation, 
etc.  It  is  also  often  necessary  in  the  routine  removal  of  the  appendix,  if  it 
happens  to  be  placed  rather  high.  If  the  appendix  is  high  and  adherent  its 
removal  through  the  Pfannenstiel  incision  may  be  attended  with  much  tech- 
nical difficulty. 

The  wound  is  sewed  up  in  layers,  and  provision  must  be  made  to  attach  the 
fascia  to  the  rectus  muscle  to  obliterate  the  dead  space  consequent  on  the 
extensive  stripping  back  of  the  fascial  flaps. 


Fig.  430. — The  Pfannenstiel  Incision. 
The  fascia  has  been  cut  transversely  and  is  being  stripped  back  from  the  rectus  muscles.     The  attach- 
ment at  the  linea  alba  is  trimmed  away  with  scissors  (after  Doderlein-Kronig). 


In  addition  to  the  cosmetic  value  of  the  incision,  other  advantages  are 
claimed  for  it.  Postoperative  hernia  is  supposed  to  be  less  common  following 
it.  Patients  are  able  to  get  up  earlier  during  convalescence  and  do  not  require 
abdominal  binders.  On  the  other  hand,  it  has  the  important  disadvantage  of 
having  considerably  greater  tendency  than  the  longitudinal  wound  to  become 
infected.  It  also  requires  more  time  during  the  operation,  both  in  making  and 
in  closing  it.  • 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


771 


^?- 


^^{.P.&-  cNi;te<-X> 


Fig.  431 — The  Pfannenstiel  Incision. 
The  fascia  has  been  stripped  back  from  the  rectus  muscles  above  and  below.     The  rectus 
muscles  have  been  separated  in  the  middle  Une  and  the  peritoneum  is  being  opened  longitudinally 
(after  Doderlein-Kronig) . 


DIASTASIS  OF  THE  RECTUS  MUSCLES 

In  order  to  determine  the  extent  of  the  diastasis  of  the  rectus  muscles  during 
a  pelvic  operation  the  left  hand  is  placed  in  the  wound,  palm  up,  with  the  middle 
finger  at  the  umbilicus.  By  lifting  up  the  abdominal  wall  with  the  hand  in  this 
position  the  thinned-out  central  portion  of  the  wall  becomes  apparent,  while 
the  edges  of  the  separated  rectus  muscles  can  be  readily  felt. 

In  most  cases  of  abdominal  relaxation  the  abnormal  separation  of  the  muscles 
extends  above  the  umbilicus.  When  the  pelvic  operation  has  been  finished  the 
skin  incision  is  enlarged  to  about  2  inches  above  the  umbilicus.  The  incision 
is  not  carried  deeper  than  the  fat.  The  skin  and  fat  layer  is  then  dissected 
wddely  away  from  the  aponeurosis  (the  attachment  of  the  umbiHcus  being 
severed)  until  the  edges  of  the  rectus  muscles  are  reached.  It  is  important  that 
the  aponeurosis  should  be  well  cleaned  of  fat.  When  all  vessels  have  been  tied, 
sutures  are  placed  in  such  a  way  as  to  infold  the  abdominal  wall  and  bring  the 
divergent  muscles  into  close  union.     This  can  best  be  done  by  employing  the 


772 


GYNECOLOGY 


''pulley  stitch"  (Fig.  433).  Beginning  at  the  upper  end  of  the  field,  a  suture  of 
some  strong  material  is  carried  first  deeply  into  the  aponeurosis  of  the  right  side 
near  the  edge  of  the  muscle;  it  is  then  introduced  superficially  into  the  apon- 
eurosis of  the  other  side;  again,  it  is  brought  back  and  passed  superficially  in 


Fig.  432. — Operation  for  Diastasis  of  the  Rectus  Muscles. 
The  fat  has  been  pushed  far  back  from  the  fascia,  the  umbilicus  cut  across.     The  thin  layer 
of  tissue  intervening  between  the  separated  recti  is  demonstrated  by  inserting  the  hand  as  in  the 
drawing.     The  edges  of  the  rectus  muscles  can  be  seen  or  felt. 


the  right  side;  and,  finally,  deeply  into  the  left  side  (Fig.  434).  When  the  ends 
of  the  suture  are  drawn  away  from  each  other  the  intervening  aponeurosis  is 
infolded  and  the  edges  of  the  muscles  are  firmly  approximated.  When  the 
suture  is  tied  the  approximation  is  greatly  reinforced.  The  suture  material  to 
be  used  depends  upon  the  extent  of  the  diastasis  and  the  amount  of  tension 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


773 


Fig.  433. — Pulley  Stitch. 

Used  for  reduplicating  the  fascia  and  approximating  the  beUies  of  the  muscles  in  operations  for  hernia 

and  diastasis  of  the  recti. 


VI^Gtcvmcs — ■ 

Fig.  434. — Operation  for  Diastasis  of  the  Rectus  Muscles  (Author's  Method). 
Introduction  of  the  pulley  stitches  through  the  fascia  at  the  borders  of  the  rectus  muscles.     Two 
fingers  of  the  left  hand  are  inserted  in  the  abdominal  wound  to  guide  the  direction  of  the  sutures  and 
to  avoid  injuring  underlying  intestine.     The  sutures  should  not  be  carried  through  the  entire  wall. 
They  include  only  the  fascia  and  part  of  the  muscular  tissue. 


requisite  to  unite  the  muscles.     If  the  tension  is  very  great,  it  is  best  to  use  a 
No.  7  braided  silk  doubled  or  strong  linen.     If  the  tension  is  moderate,  No.  2 


774 


GYNECOLOGY 


chromicized  catgut  doubled  may  suffice.     The  object  in  doubling  the  suture  is  to 
avoid  cutting  through  the  tissues. 

The  approximation  pulley  stitches  are  placed  about  |  or  |  inch  apart,  down 
to  the  upper  end  of  the  primary  incision,  or,  if  the  incision  is  a  very  long  one,  to 
about  2|  inches  below  the  umbilicus. 


V^.l^Svovvee., 


Fig.  435. — Operation  for  Diastasis  of  the  Rectus  Muscles  (Author's  Method). 
Pulley  stitches  have  been  introduced  through  the  fascia  at  the  borders  of  the  separated  recti. 
The  lower  part  of  the  wound  where  the  incision  into  the  abdominal  cavity  has  been  made  is  closed  in 
layers  in  the  usual  way,  the  rectus  muscles  lying  in  close  approximation  after  the  pulley  stitches  have 
been  drawn  and  tied. 


The  use  of  the  pulley  stitch  is  the  most  powerful  method  of  approximating 
tissues  that  we  possess  and  can  be  used  in  most  cases  where  great  tension  must 
be  overcome. 


OPERATIONS    ON    THE    ABDOMINAL    WALL 


775 


OPERATION   FOR   UMBILICAL   HERNLA.   (AUTHOR'S   METHOD) 

The  basic  principle  involved  in  this  operation  is  that  in  order  to  secure 
adequate  support  for  the  new  wound  and  to  insure  against  a  recurrent  hernia 
of  the  scar,  the  rectus  muscles,  which  in  all  cases  of  umbilical  hernia  are  separated, 
must  be  reunited  not  only  at  the  site  of  the  hernia,  but  for  a  considerable  dis- 
tance above  and  below. 

A  long  incision  is  therefore  made,  as  in  Fig.  437,  in  the  median  hne  above 
and  below,  but  encirchng  the  protruding  mass.  The  first  step  is  to  dissect  out 
the  sac,  cutting  deeply  in  the  surrounding  fat  until  the  white,  firm  tissue  of  the 
aponeurosis  over  the  rectus  muscles  is  reached.  The  dissection  is  then  carried 
on  until  the  hernial  ring  is  clearly  developed.  When  the  sac  is  very  large  it  is 
often  found  lying  far  over  on  the  side  of  the  abdomen,  more  or  less  adherent  to 
the  aponeurosis  (Fig.  436).  To  one  unfamiliar  with  this  condition  the  develop- 
ment of  the  ring  is  at  first  confusing. 


\jmba 


Fig.  436. — Umbilical  Herota. 
Transverse  section  of  abdomen  showing  diastasis  of  recti,  hernial  sac,  and  adhesion  of  intestines 
and  omentum  to  the  sac  wall.     The  waj-  in  which  the  hernial  sac  folds  over  on  the  fascia  and  becomes 
one-sided  is  shown.     Also  the  disappearance  of  fat  immediately  over  the  hernia. 

"WTien  the  sac  and  ring  have  been  clearly  exposed  an  attempt  is  made  to 
empty  the  sac  of  its  contents,  which  cannot  be  done  if  there  are  adhesions  inside 
the  sac  or  along  the  edge  of  the  ring.  If  there  are  no  adhesions  the  sac  is  opened 
and  trimmed  off  at  the  ring.  If  adhesions  are  present  the  sac  must  be  opened 
with  great  care,  so  as  not  to  injure  a  possible  loop  of  intestine.  The  adhesions 
of  the  omentum  or  intestines  to  the  inner  surface  of  the  sac  and  the  ring  are 
freed  and  the  contents  dropped  back  into  the  abdominal  cavity.  The  freeing  of 
the  adhesions  may  be  attended  with  much  difficulty.  In  our  experience  the 
best  and  safest  technic  in  this  tedious  task  is  the  use  of  the  Mixter  curved 
dissecting  scissors.  The  temptation  to  use  gauze  dissection  should  in  all  cases 
be  resisted,  for  no  other  method  is  so  prolific  of  trauma  to  the  intestines.    An 


776 


GYNECOLOGY 


important  maneuver  in  the  dissection  of  adhesions  involving  the  bowel  is  to 
loop  the  left  forefinger  under  the  adhesion  and  hft  it  firmly  up.  By  this  means 
a  resisting  surface  is  given  for  the  dissection,  and,  at  the  same  time,  a  better 
opportunity  for  differentiating  the  tissues. 

In  freeing  the  adhesions  from  the  edge  of  the  ring  it  will  usually  be  found 
that  they  involve  a  considerable  margin  of  the  peritoneal  surface  around  the 
ring.  All  the  adhesions  should  conscientiously  be  freed — not  only  those  attach- 
ing omentum  and  intestine  to  the  peritoneum  of  the  sac  and  abdominal  wall, 
but  also  those  uniting  loops  of  intestines  together.     If  injury  is  done  to  the 


'V(P.GrB>v«u's- 

FiG.  437. — Umbilical  Hernia  (Author's  Method). 
The  incision  is  indicated  by  the  red  line. 


seromuscular  coat  of  the  intestinal  wall,  it  must  be  repaired  with  fine  catgut. 
In  some  cases  it  is  advantageous  to  graft  a  piece  of  omental  fat  over  raw  surfaces 
that  cannot  otherwise  be  protected. 

When  all  adhesions  have  been  released  the  omentum  is  pulled  clown  under 
the  wound  and  a  flat  gauze ^  handkerchief  inserted.  The  skin  wound  is  then 
greatly  enlarged  by  extending  the  median  incision  toward  the  pubes  and  toward 
the  ensiform  cartilage.  The  fascia  on  each  side  of  the  wound  is  widely  exposed 
by  dissecting  back  the  fat.  At  this  point,  in  the  case  of  a  large  hernia,  the  skin 
wound  extends  nearly  the  whole  length  of  the  abdomen. 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


777 


The  ragged  remnants  of  the  hernial  sac  are  now  trimmed  away  and  the 
wound  through  the  abdominal  wall  extended  downward,  but  not  upward. 

Next  the  layers  of  the  abdominal  wall  are  cleanly  dissected  out  and  isolated 
in  the  lower  half  of  the  wound,  but  not  in  the  upper  half.  This  will  be  under- 
stood by  referring  to  Fig.  435.    In  order  to  expose  the  bellies  of  the  rectus  muscles 


W.^.GrtwjcS-: 


Fig.  438. — Umbilical  Hernia. 
The  hernial  sac  has  been  dissected  away  from  the  surrounding  abdominal  fat  and  lifted  up  from 
the  fascia.     The  sac  is  being  cut  away  at  the  hernial  ring.     If  the  sac  contains  adherent  omentum 
and  loops  of  gut  the  opening  must  be  made  in  the  most  convenient  place,  and  all  adhesions  of  the  sac 
and  ring  removed  before  the  sac  is  trimmed  off. 


it  is  necessary  to  run  the  scissors  along  the  inner  edge  of  the  sheath  which  encloses 
them. 

The  next  step  is  the  application  of  sutures  so  as  to  approximate  the  rectus 
muscles  along  their  entire  length,  and  in  doing  so  the  plan  is  to  bring  them 
together  by  reduplication  of  the  fascia  in  the  upper  half  and  by  union  of  the 


778 


GYNECOLOGY 


layers  in  the  lower  half.  The  reason  for  this  is,  that  if  the  layers  of  the  upper 
half  are  dissected  out  and  an  attempt  made  to  approximate  them,  it  will  be 
found  that  they  are  unable  to  stand  the  tension.  The  muscles,  however,  can 
be  brought  together  by  reduphcation  of  the  uninjured  fascia,  which  is  very  power- 


FiG.  439. — Abdominal  Hernia  (Author's  Method). 
Stitches  tied.     The  stitches  of  the  upper  single  row  are  all  pulley  stitches.     If  there  is  much 
tension,  they  should  be  of  strong  silk  or  linen.     If  the  tension  is  only  moderate,  strong  catgut  (No  2 
chromicized)  is  sufficient.     The  fascia  of  the  lower  part  of  the  wound  is  overlapped  and  sewed  with 
two  rows  of  interrupted  chromic  catgut  sutures. 

ful.  It  will  be  found  that  when  the  upper  half  of  the  recti  are  reunited  in  this 
way  the  beUies  of  the  lower  half  lie  closely  together,  requiring  no  further  tension 
to  approximate  them. 

In  placing  the  sutures  the  peritoneum  is  first  sewed  for  a  few  inches,  the 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


779 


end  of  the  suture  being  left  long.  The  left  hand  is  then  inserted  beneath  the 
layer  of  tissue  that  intervenes  between  the  separated  recti  muscle  and  a  series 
of  pulley  stitches  apphed,  beginning  at  the  top  of  the  wound  (Fig.  434).  If  no 
very  great  tension  is  required,  they  may  be  of  No.  2  chromicized  catgut  doubled. 
If  great  tension  is  necessary  to  approximate  the  edges  of  the  muscles,  it  is  neces- 


FiG.  440. — Abdominal  HER>nA  (Author's  Method). 
The  fat  of  one  side  is  stitched  down  over  the  row  of  sutures  in  the  fascia.     This  is  to  protect  them 
in  case  of  -n-ound  sepsis  and  is  especially  important  when  silk  or  linen  has  been  used.     A  cigarette 
drain  is  placed  in  the  wound  through  a  lateral  stab-wound.     It  is  a  good  plan  to  leave  the  end  of  the 
drain  long  enough  so  that  it  can  be  withdrawn  without  disturbing  the  dressing  and  binder. 


sary  to  use  a  non-absorbable  stitch,  either  No.  7  braided  silk  or  strong  Pagen- 
stecher  hnen.  The  suture  should  usually  be  doubled  to  insure  against  cutting 
through  the  tissues. 

The  pulley  stitches  are  apphed  as  pictured  in  Fig.  434,  the  left  hand  guarding 
against  possible  puncture  of  the  abdominal  wall  and  injury  to  the  bowel.     They 


780 


GYNECOLOGY 


should  not  be  carried  through  the  peritoneum,  but  may  dip  deeply  into  the 
muscle. 

After  placing  the  pulley  stitches  they  are  drawn  tight  and  tied.  The  suture 
of  the  peritoneum  is  then  completed  and  several  interrupted  catgut  stitches 
inserted  in  the  rectus  muscles,  which  now  lie  in  close  union.  The  fascia  of  the 
lower  half  of  the  wound  is  overlapped  as  depicted  in  Fig.  439. 

We  now  have  a  very  long  wound,  usually  with  much  fat,  and  numerous  bulky 
knots  in  the  fascia,  all  factors  favorable  for  sepsis.     In  order  to  provide  against 


Fig.  441. — The  Mayos'  Operation  for  Umbilical  Hernia. 
Showing  the  position  of  the  initial  incision  and  the  hernial  ring  after  dissection  of  the  sac. 


this,  the  fat  of  one  side  of  the  wound  is  stitched  with  fine  catgut  to  the  fascia  so 
as  to  cover  and  protect  the  line  of  sutures.  In  order  to  prevent  the  accumula- 
tion of  serum  and  dissolved  fat  in  the  wound  it  is  drained  by  a  Penrose  tube 
passed  through  a  stab-wound.  The  end  is  left  long  enough  so  that  it  may  be 
extracted  in  two  or  three  days  without  disturbing  the  dressing. 

In  applying  the  dressing  a  continuous  strapping  with,  surgeon's  plaster 
should  be  used.  The  most  effective  swathe  is  the  three-tailed  binder  devised 
by  Rockey. 

The  patient  should  be  kept  in  bed  three  weeks. 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


781 


THE  MAYOS'  OPERATION  FOR  UMBILICAL  HERNLA 

A  simple  and  popular  method  of  operating  on  umbilical  hernia,  and  one 
from  which  excellent  results  are  reported,  has  been  devised  by  the  Mayos. 

It  consists  in  making  a  large  transverse  elliptic  incision  including  the  hernia 
and  a  considerable  amount  of  adjacent  fat.  The  hernial  mass  is  removed  as  in 
the  preceding  operation,  the  sac  opened,  and  all  adhesions  freed.  The  wound 
in  the  fascia  is  enlarged  transversely  until   the   edges  of   the  rectus   muscles 


Fig.  442. — The  Mayos'  Operation  for  Umbilical  Heristia. 
The  hernial  sac  has  been  removed.     The  fascia  is  being  overlapped  and  secured  by  mattress  sutures. 


are  reached.  The  upper  flap  of  fascia,  together  with  its  peritoneal  lining,  is 
then  lapped  over  the  under  flap,  and  attached  in  this  position  by  a  row  of  mat- 
tress sutures  passed  from  the  edge  of  the  lower  flap.  The  edge  of  the  upper 
flap  is  stitched  down  on  the  underlying  fascia. 

Numerous  other  excellent  operations  have  been  devised.  Graser  performs 
an  operation  which  combines  the  principles  of  the  two  operations  described 
above.  He  makes  a  transverse  incision,  dissects  out  and  approximates  the 
rectus  muscles,  and  sews  up  the  fascia  transversely.  Blake  and  Webster  have 
developed  operations  similar  in  principle  to  the  first  operation  described. 


782 


GYNECOLOGY 


OPERATION  FOR  POSTOPERATIVE  HERNIA 

The  operation  for  postoperative  hernia  used  by  the  author  is  in  principle 
like  that  for  umbilical  hernia,  though  for  hernias  that  occur  in  scars  of  low- 
pelvic  operations  the  wound  need  not  be  so  long.  The  principle  to  be  observed 
is  to  unite  the  rectus  muscles  at  a  considerable  distance  above  the  hernia, 
so  that  at  the  site  of  the  hernia  there  is  no  lateral  tension  in  approximating 
the  edges  of  the  various  layers  of  the  abdominal  wall.     The  method   of  re- 


FiG.  443. — The  Mayos'  Operation  for  Umbilical  Hernia. 
Final  step  of  overlapping  and  securing  the  fascia. 

duphcating  the  fascia  at  the  point  where  there  is  greatest  tension  instead  of 
dissecting  out  the  layers  is  to  be  observed  in  these  hernias,  as  in  the  umbiUcal 
type. 

TRANSPLANTATION  OF  FASCIA  FOR  POSTOPERATIVE  HERNIA 

In  some  cases  of  abdominal  hernia  neither  the  operation  of  approximating 
the  rectus  muscles  nor  the  overlapping  of  flaps  of  fascia  is  feasible  on  account  of 
causing  too  great  tension  on  the  tissues  of  the  abdominal  wall.  In  order  to  meet 
this  contingency  various  devices  have  been  employed,  such  as  the  insertion  of 


OPERATIONS  ON  THE  ABDOMINAL  WALL 


783 


metal  plates,  wire  gauze,  etc.  These  methods,  though  occasionally  successful, 
are  imsatisfactory  and  in  principle  unsurgical. 

A  more  rational  method  that  bids  fair  to  become  of  great  importance  in  the 
treatment  has  recently  been  introduced,  and  consists  in  the  transplantation 
to  the  abdominal  wall  of  fascia  taken  from  the  thigh.  The  technic  employed 
by  WiUard  Bartlett  and  depicted  in  Figs.  444-446  is  as  follows: 

A  free  incision  is  made  over  the  hernial  area  and  the  skin  and  fat  widely 
dissected  away  from  the  margin  of  the  sac  or  thinned  out  portion  of  the  ab- 


Fig.  444 TRANSPLuiXTATioN  of  Fascia  Lata  for  Postoperatr-e  Herxia  (Bartlett's  Method). 

The  letter  H  incision  on  the  outside  of  the  thigh. 

dominal  wall,  as  in  the  other  operations  for  hernia.  If  it  is  seen  that  the  edges 
of  the  ring  cannot  be  brought  together  without  too  great  tension,  the  incision 
is  carried  no  further  and  the  wound  is  covered  with  a  sterile  dressing.  With 
the  patient  still  on  her  back,  the  right  leg  is  exposed  and  flexed  in  the  position 
shown  in  Fig.  444,  After  a  thorough  skin  preparation,  preferably  with  iodin,  a 
long  H  incision  is  made  in  the  middle  of  the  lateral  aspect  of  the  thigh.  The 
length  of  the  incision  depends  on  the  amount  of  fascia  that  it  is  desired  to  re- 
move. As  a  rule,  a  generous  flap  is  necessary,  and  the  incision  will  occupy  the 
middle  three-quarters  of  the  hne  extending  from  the  great  trochanter  to  the 


784 


GYNECOLOGY 


external  condyle  of  the  leg.  The  cross-incisions  at  the  ends  of  the  longitudinal 
cut,  forming  a  letter  H,  enable  the  .surgeon  to  expose  a  very  wide  area  of  fascia 
without  impairing  too  much  the  circulation  of  the  skin-flaps,  thus  avoiding  any 
possible  danger  of  later  necrosis  and  sloughing.  The  skin  and  fat  of  the  thigh 
are  dissected  from  the  fascia  lata  from  the  edge  of  the  sartorius  in  front  of  the 
thigh  to  the  edge  of  the  semimembranosus  behind.     The  fascial  flap  is  removed 


Fig.  445. — Transplantation  of  Fascia  Lata  for  Postoperative  Herota  (Bartlett's  Method). 
Showing  method  of  dissecting  fascia  from  thigh. 

in  the  form  -of  a  parallelogram  and  placed  in  warm  normal  salt  solution  until 
needed.     The  wound  of  the  leg  is  closed. 

The  abdominal  wound  is  then  uncovered.  Without  making  any  incision 
in  the  fascia  the  hernial  protrusion  is  inverted  and  the  edges  of  the  turned-in 
portion  sutured  with  catgut,  care  being  exercised  not  to  pierce  the  fascia  so 
deeply  as  to  injure  a  loop  of  intestine  that  may  be  closely  adherent  beneath. 


OPERATIONS    ON   THE   ABDOMINAL   WALL 


785 


The  flap  of  fascia  lata  is  removed  from  the  saHne  solution  and  cut  in  the 
center,  the  two  pieces  being  sewed  together  so  that  the  fibers  of  both  pieces  in 
the  new  parallelogram  thus  formed  will  run  transversely  instead  of  longitudinally, 
as  in  the  first  piece.     A  glance  at  Fig.  446  will  explain  this  point.     This  maneuver 


^ 


Fig.  446. — Transplan'tation  of  Fascia  Lata  Fobj  Abdominal  Hernia  (Bartlett's  Method). 
The  piece  of  fascia  lata  removed  from  the  thigh  has  been  cut  in  two  and  the  pieces  laid  side- 
wise  so  that  the  direction  of  the  fibers  will  be  at  right  angles  to  those  of  the  abdominal  fascia.     The 
layer  of  fascia  covering  the  hernia  has  been  reduplicated  by  a  running  suture,  the  ends  of  which  can 
be  seen  above  and  below  the  transplanted  fascia. 


is  carried  out-  so  that  the  fibers  of  the  transplanted  flap  will  not  coincide  in 
direction  with  those  of  the  abdominal  fascia  covering  the  hernia.  The  layer 
of  fascia  lata  is  then  stitched  to  the  abdominal  wall  over  the  inverted  hernia 
(Fig.  446).  The  wound  is  closed  with  a  stab-wound  drain  placed  as  in  Fig.  440, 
The  denuded  muscles  of  the  leg  become  rapidly  invested  in  a  new  sheath. 

50 


786  GYNECOLOGY 

Valuable  work  in  fascial  transplantation  has  been  done  by  H.  A.  Shaw,  who 
epitomizes  the  essential  principles  of  technic  in  the  following  concrete  form : 

"Essentials  of  Fascial  Transplantation. — In  selecting  a  transplant  it  has  been  repeatedly 
demonstrated  that  tissue  which  normally  is  poorly  vascularized  is  much  better  adapted  than 
highly  vascularized  tissue.  For  the  first  few  days  the  transplant  must  obtain  its  chief  nom-ish- 
ment  from  the  lymph  exudate,  supphed  by  the  tissues  surrounding,  and  eventually  from  the 
ordinary  source  due  to  the  vascular  connections  formed  in  the  new  home.  Therefore,  the  less 
■vascular  the  transplant  and  the  more  vascular  the  soil,  the  greater  assurance  of  success. 

"In  the  selection  of  tissue  for  the  purpose  of  transplantation,  from  a  histologic  standpoint 
it  seems  to  be  more  of  a  question  of  vascularization  than  of  any  peculiarity  or  arragement  of  its 
cellular  constituents,  although  'the  higher  the  development  of  the  cell,  as  ganghon-cell,  nerve- 
cell,  muscle-cell,  etc.,  the  less  likely  js  it  to  sxurvive.' 

"Therefore  in  order  of  their  importance  would  be,  first,  low  normal  vascularity,  second, 
simple  cellular  structure.  Fascia  to  an  admirable  extent  answers  both  requirements  and,  in 
addition,  has  great  tensile  strength,  which  adds  materially  to  its  value  in  a  great  number  of 
indications.  'It  can  be  transplanted  with  almost  uniform  success  and  is  much  more  sure  of 
success  than  the  ordinary  skin  graft.' 

"Fascial  transplants  m  common  wdth  all  tissue  transplants  may  be  (1)  autoplastic  (same 
subject),  (2)  homoplastic  (same  species),  (3)  heteroplastic  (another  species). 

"(1)  Autoplastic  transplants  of  fascia  lata,  when  fresh  and  transplanted  under  careful 
technic,  are  almost  as  sure  to  take  as  normal  fascia  is  to  unite  after  suturing.  It  is  a  material 
that  is  always  available  with  a  minimum  amount  of  injury  to  the  part  from  which  it  is  obtained 
and,  therefore,  either  homo-  or  heteroplasty  would  have  no  great  advantage  even  if  of  equal 
success.     Autoplastic  fascial  transplants  undergo  practically  no  histologic  metamorphosis. 

"(2)  Homoplastic  transplants  of  fascia  lata  usually  take,  but  undergo  histologic  change, 
wherein  the  elastic  tissue  is  replaced  by  fibrous,  thereby  losing  one  of  its  most  valuable  proper- 
ties under  certain  conditions,  and  in  this  respect  preserved  autoplastic  tissue  acts  the  same 
as  homoplastic.  Success  of  homoplastic  flaps  probably  depends  more  or  less  upon  the  similarity 
of  the  blood-serum  of  the  donor  and  recipient. 

"  (3)  Heteroplastic  transplants  only  act  as  support  for  the  new  formed  cells,  while  the  old 
cells  are  being  resorbed,  fibrous  tissue  usually  being  substituted  for  the  transplant.  There- 
fore, if  the  formation  of  new  cells  be  at  least  as  rapid  as  the  absorption  of  the  old,  we  obtain  a 
result  that  would  be  a  clinical  success  but  a  histologic  failure.  Herein  enters  a  great  element 
of  chance.  Fascia  is  so  easily  obtainable  in  such  liberal  amounts  that  heteroplasty  should 
not  be  resorted  to  and  is  mentioned  simply  to  condemn. 

"  Technic. — To  insm-e  success  in  fascial  transplantation  we  should  adhere  strictlj^  to  the 
following  rules: 

"  (1)  Handle  Gently. — In  this  respect  we  should  keep  constantly  in  mind  the  fact  the  more 
mechanical  injury,  the  less  the  vitality  of  oiu-  transplant,  andJhere  I  would  suggest  sharp  dis- 
section of  our  transplant  at  those  points  where  it  is  intimate  with  intramuscular  septa,  thus 
minimizing  trauma. 

"  (2)  Keep  Transplant  Moist  and  Warm. — 1  would  suggest  where  practical  to  prepare  your 
field  completel}'  for  the  reception  of  the  transplant  and  suture  in  situ  immediately.  Some- 
times this  will  be  impractical,  if  so,  keep  transplant  in  physiologic  salt  solution  at  normal 
temperature.  The  advantage  of  immediate  suture  is  the  fact  that  our  fascia  loses  none  of  its 
contained  lymph  by  osmosis  with  salt  solution  and  does  not  become  dry  or  cold. 

"(3)  Keep  Free  from  Antiseptics. — The  same  principle  appHes  here  as  in  skin  grafting. 
Therefore  do  not  prepare  patient  by  dry  (benzin-iodin)  method;  do  not  use  iodized  gut; 
allow  no  possible  contact  with  antiseptics. 

"  (4)  Transplant  Must  Come  in  Close  Contact  with  Tissue  and  be  Maintained  in  that  Position. 
— This  is  important  in  establishing  the  future  circulation  of  the  transplant,  as  we  can  readily 
see  how  impossible  it  would  be  for  our  delicately  budding  embryologic  vessels  to  bridge  over 
any  amount  of  dead  space,  and  how  imperfectly  maintained  contact  would  disintegrate  our 


OPERATIONS  ON  THE  ABDOMINAL  WALL  787 

granulating  vascular  loops.  A  firmly  applied  equal  pressure  bandage  is  of  great  service  in 
this  respect. 

"(5)  Minute  Attention  to  Every  Aseptic  Detail. — While  infection  does  not  absolutely  spell 
failure,  or  failure  may  involve  only  a  limited  area  of  the  transplant,  yet  an  aseptic  conscience  is 
the  first  essential  of  successful  fascial  transplantation.  We  fully  realize  that  under  normal 
circumstances  the  tissues  will  care  for  a  certain  number  of  micro-organisms,  but  here  we  have 
tissue  completely  cut  oS  from  its  normal  blood-supply  and  whose  resistance  is  practically 
nil;  tissue  that  must  derive  its  im^mediate  nourishment  from  the  surrounding  lymph  exudate 
which,  if  d'luted  with  an  infiamm.atGry  transudate,  would  furnish  poor  nourishment  and  pre- 
vent the  intimate  contact  between  the  transplant  and  its  new  home. 

"  (6)  Perfect  Hemostasis. — Here  again  we  deal  with  an  interference  with  proper  nutrition 
and  a  creator  of  dead  space. 

"(7)  Transplant  Must  be  Kept  on  a  Stretch. — Otherwise  it  will  become  shortened  and 
possibly  be  replaced  by  fibrous  tissue.  In  other  words,  it  must  be  placed  in  as  near  its  physio- 
logic environment  as  possible.  The  elastic  fibers  in  fascia  lata  normally  keep  it  in  intimate 
contact  with  the  muscle,  allowing  for  contraction  and  expansion.  When  removed  there  is  a 
primary  contraction  due  chiefly  to  the  elastic  fibers  that  is  com.plete  in  a  fev/  moments.  This 
is  practically  overcome  by  tacking  in  place  immediately  upon  removal  or,  better  still,  by  the  aid 
of  forceps  as  recommended  by  Dr.  Guleka." 

OPERATION   FOR   FEMORAL   HERNIA 

Femoral  hernia  is  so  rare  in  men  and  so  common  in  women  that  it  must  be 
classified  as  a  gynecologic  disease. 

The  operation  for  femoral  hernia  is  usually  regarded  as  a  simple  procedure, 
and  so  it  is  in  many  cases.  The  operation  in  common  use  consists  in  cutting 
down  to  the  hernial  mass,  either  from  an  inguinal  hernia  incision  or  by  a  longi- 
tudinal incision  immediately  over  the  protrusion.  The  hernial  sac  is  found  en- 
cased in  a  mass  of  fat  which  often  renders  the  isolation  and  opening  of  the  sac 
extremely  difficult,  especially  if,  as  is  frequently  the  case,  the  sac  is  small.  When 
the  sac  has  been  found  it  is  freed  from  the  surrounding  fat,  emptied  of  its  con- 
tents, and  tied  off  as  high  as  possible.  No  attempt  is  made  to  close  in  the  ring,  as 
there  is  no  anatomic  exposure  of  the  tissues  and  a  blind  placing  of  deep  stitches 
would  be  ineffectual  and  dangerous.  In  the  average  case  the  hernial  opening  is 
very  small,  so  that  recurrence  is  not  common.  In  many  instances,  however, 
the  opening  is  stretched  and  relaxed,  so  that  the  simple  tying  of  the  sac  without 
closure  of  the  femoral  ring  is  quite  inadequate  and  may  result  in  recurrence. 

An  ingenious  and  effective  radical  operation  for  femoral  hernia  has  been  pre- 
sented by  Moschowitz  and  later  emphasized  and  illustrated  by  Seilig  andTuhol- 
ske.  The  principle  of  the  operation  involves  an  approach  to  the  hernia  through 
the  inguinal  canal.  The  femoral  ring  is  exposed  from  behind,  the  sac  emptied 
of  its  contents,  drawn  backward,  and  tied.  The  ring  is  closed  by  suturing  Pou- 
part's  hgament  to  a  powerful  tendinous  band,  the  so-called  Cooper's  hgament, 
which  hes  posterior  to  the  femoral  ring.  The  details  of  the  operation  are  as 
follows : 

The  incision  usually  employed  for  repair  of  inguinal  hernia  is  made.  In 
order  to  secure  greater  exposure  this  incision  may  be  carried  further  down  toward 
the  pubes,  or,  if  necessity  require,  it  may  be  extended  by  a  right-angle  incision 


788 


GYNECOLOGY 


toward  the  thigh.  The  aponeurosis  of  the  external  obHque  is  then  divided  and 
the  conjoined  tendon  exposed.  The  round  hgament  is  isolated  and  hfted  out  of 
the  way  by  a  loop  of  tape.  The  thin  layer  of  transversahs  fascia  is  incised  and 
the  peritoneum  brought  to  view.  If  the  parts  be  now  retracted  as  in  Fig.  447, 
the  neck  of  the  sac  as  it  passes  through  the  femoral  ring  comes  into  view.  At 
this  point  in  the  operation  a  knowledge  of  the  anatomy  is  essential.  The  crural 
ring  is  bounded  externally  by  the  external  ihac  vein,  anteriorly  by  Poupart's 
ligament,  internally  by  Gimbernat's  ligament,  and  posteriorly  by  Cooper's  liga- 
ment.    Just  beyond  the  external  ihac  vein  is  the  deep  epigastric  artery  which  may 


Tas-cvcx- 


FiG.  447. — Opebation  fob. Femoral  Heekia  (Moschowitz). 

An  inguinal  incision  has  been  made  and  the  peritoneum  exposed,  bringing  to  view  the  neck  of 

the  hernial  sac  as  it  enters  the  femoral  ring. 


be  encountered  in  opening  the  transversahs  fascia.  It  should  be  remembered 
that  near  the  edge  of  Gimbernat's  ligament  there  may  run  an  anomalous  obtu- 
rator artery,  the  so-called  corona  mortis,  the  cutting  of  which  is  likely  to  cause 
serious  trouble. 

The  next  step  of  the  operation  is  to  incise  the  peritoneum  near  the  neck  of  the 
sac  and  to  pull  the  contents  of  the  sac  (intestine  or  omentum)  back  into  the  ab- 
dominal cavity.  Usually  the  contents  are  not  adherent  to  the  sac.  If  they  are 
adherent  traction  on  the  contents  will  pull  the  entire  hernial  mass  through  the 
ring  and  convert  it  into  an  inguinal  hernia.     If  the  mass  is  adherent  to  the 


OPERATIONS    ON    THE,  ABDOMINAL    WALL 


789 


thigh  it  may  be  necessary  to  extend  the  incision  and  dissect  out  the  sac  in  the 
usual  way. 

In  case  of  a  strangulated  hernia  the  opening  is  enlarged  by  incising  Gimber- 
nat's  ligament,  care  being  taken  not  to  cut  an  aberrant  obturator  artery. 

If  the  contents  of  the  sac  are  readily  drawn  back  a  dressing  forceps  is  then 
passed  through  the  ring,  applied  to  the  wall  of  the  sac  and  drawn  backward,  thus 
bringing  the  sac  into  view.     The  sac  is  tied  off  in  the  usual  way  as  high  as  possible. 


Fig.  44S. — Operation  for  Femoral  Hernia  (Moschowitz). 
The  peritoneal  sac  has  been  opened  and  the  contents  of  the  hernia  drawn  backward  through 
the  femoral  ring  into  the  abdominal  cavity.     The  sac  has  been  drawn  out,  tied,  and  cut.     Cooper's 
ligament  and  Poupart's  ligament  are  being  united,  thus  closing  the  femoral  ring. 


The  next  step,  which  is  the  most  important  part  of  the  operation,  is  the 
closure  of  the  ring.  The  parts  are  fully  retracted.  Along  the  horizontal  ramus 
of  the  pubes  and  projecting  from  it  is  a  dense,  tough,  white,  glistening  membrane, 
which  is  Cooper's  hgament.  Two  or  three  sutures  of  chromic  catgut  are  then  so 
placed  as  to  unite  Cooper's  and  Poupart's  Hgament.  The  first  suture  passes 
deeply  through  Cooper's  hgament  just  internal  -to  the  external  iliac  vein.  It 
then  includes  the  cut  edge  of  the  transversalis  fascia  and  Poupart's  ligament 
(Fig.  448).  The  other  sutures  are  similarly  placed,  the  innermost  one  including 
a  bite  in  Gimbernat's  ligament. 


790 


GYNECOLOGY 


The  final  step  of  the  operation  is  like  that  for  inguinal  hernia.  The  con- 
joined tendon  is  sutured  to  Poupart's  hgament  and  the  aponeurosis  of  the  ex- 
ternal oblique,  united  by  an  mibricating  stitch. 


THE  PERCY  CAUTERY  FOR  CANCER  OF  THE  CERVIX 

In  applying  the  principles  of  the  Percy  cauterization  it  is  necessary  to  have 
a  special  equipment.  This  consists  chiefly  of  several  electric  heating  irons  with 
an  assortment  of  tips  and  a  water-cooled  vaginal  speculum  (Figs.  449,  450). 


>v<i  ■p.fer 


Fig.  449. — Percy  Cautery  with  Some  of  the 
Points  with  which  it  is  Equipped. 


Fig.    450. — Water-cooled     Speculum     Used 
WITH  Percy  Cautery. 
The  speculum  should  be  used  only  when  the 
vagina  is  sufficiently  relaxed  to  admit  the  specu- 
lum without  injuring  the  mucous  membrane. 


The  patient  is  prepared  for  a  combined  vaginal  and  abdominal  section,  the 
legs  being  elevated  to  secure  the  ordinary  perineal  posture,  while  the  table  is 


OPERATIONS    ON    THE    ABDOMINAL   WALL 


.791 


set  in  the  Trendelenburg  position.  The  abdomen  is  first  opened  and  the  pelvis 
explored.  The  intestines  are  thoroughlj^  packed  away.  The  two  internal  ihac 
arteries  are  tied  and  the  tubes  and  ovaries  removed.  This  is  done  in  order  to 
check  as  far  as  possible  the  blood-supply  to  the  uterus.  Percy  regards  this  as 
important  to  avoid  the  secondary  hemorrhages  which  sometimes  follow  the  use 
of  low  degrees  of  heat.  While  the  abdomen  is  being  opened  the  vagina  is  being 
dilated  by  a  second  operator  and  the  water-cooled  speculum  inserted. 

The  heating  iron  is  next  apphed,  with  the  tip  adjusted  that  is  most  suitable 
for  reaching  the  diseased  area  of  the  particular  case.     The  two  operators  now 


-^  Qss\?,tcvv\t:  m 
\  Cxfea omen 


Fig.  451. — The  Percy  Cautery,  Showing  Method  of  Application. 


work  together.  The  abdominal  operator  can  by  holding  the  uterus  give  direc- 
tions as  to  how  far  the  heating  iron  maj^  be  inserted,  and  by  downward  pressure 
place  the  uterus  in  a  more  convenient  position  for  applying  the  heat.  The  iron 
is  kept  at  a  comparatively^  low  temperature.  Percy  lays  great  emphasis  on 
avoiding  the  charring  of  the  tissues,  for  once  a  char  is  formed  it  prevents  the 
penetration  of  the  heat  into  the  surrounding  tissues.  In  order  to  test  the  amount 
of  heat  before  inserting  the  iron  it  is  first  apphed  to  wood.  If  the  wood  is  char- 
red the  iron  must  be  regarded  as  too  hot.  When  the  iron  has  been  brought  to 
the  required  heat  it  is  inserted  in  the  carcinomatous  mass.  Percy  recommends 
that  it  always  be  carried  to  the  fundus  of  the  uterus  even  if  it  is  necessary  to 


792 


GYNECOLOGY 


incise  the  cervical  canal.  We  have  not  usually  found  it  feasible  to  force  the 
entrance  as  far  as  the  fundus.  The  length  of  the  appHcation  is  determined  by 
the  abdominal  operator  who  holds  the  ; 

uterus  firmly   grasped   in   his    gloved  ■  i 

hand.  The  iron  is  withdrawn  when  the 
uterus  becomes  so  hot  that  the  opera- 
tor can  no  longer  hold  it  comfortably. 
The  heat  attained  is  from  110°  to  120° 
F.  and  the  time  of  application  to  one 
place  from  fifteen  to  twenty  minutes. 
The  iron  is  then  shifted  to  some  other 
point  in  the  diseased  tissue  and  the 
process  repeated.  When  the  treatment 
is  appHed  to  tissues  involving  the  rec- 
tum or  bladder  specially  constructed 
thermometers  are  used.  The  whole 
operation  takes  from  one  to  two  hours. 


Fig.  452. — Application  of  Radium. 

Method  of  attaching  radium  to  a  silver  or  gold 

coin  with  a  strip  of  adhesive  plaster. 


"Vsf.'V^ 


Fig.  453. — Application  of  Radium. 
Method  of  enclosing  radium  tubes  attached 
to  a  coin  in  a  rubber  cot.     The  coin  and  tubes 
are  first  wrapped  in  gauze  before  insertion  into 
the  cot. 


TECHNIC  IN   THE  APPLICATION   OF  RADIUM 

There  is  at  present  no  standardized  technic  in  applying  radium  to  cancer  of 
the  cervix.  The  methods  here  described  are  those  employed  by  the  author,  and 
have,  for  the  most  part,  been  adapted  or  modified  from  other  clinics.  They 
relate  only  to  the  direct  use  of  radium  salts. 

In  employing  radium  in  the  treatment  of  cervical  cancer  the  most  important 
consideration  is  the  avoidance  of  injury  to  the  sound  tissues  and  the  prevention 
of  later  fistulse.    Too  great  emphasis  cannot  be  laid  on  this  point. 

When  the  cancerous  area  presents  itself  as  a  symmetric  growth  into  the 


OPERATIONS    ON    THE    ABDOMINAL    WALL 


793 


vagina  a  simple  and  convenient  method  of  application  is  that  pictured  in  Figs. 
452,  453.  In  this  instance  three  silver  tubes  containing  radium  salts  are  fas- 
tened to  a  50-cent  piece  bj^  a  small  strip  of  adhesive  plaster.  The  coin  and  tubes 
are  wrapped  in  several  layers  of  gauze  and  tied  in  the  end  of  a  rubber  finger  cot. 
For  the  first  apphcation  it  is  advisable  to  anesthetize  the  patient,  for  in  this  way 
the  radium  may  be  much  more  accurately  placed.    The  vagina,  which  should  be 


r^oVbair 


Fig.  454. — Application  of  Radil^m. 
Method  of  attaching  radium  tubes  to  a  piece  of  sheet  lead,  wrapping  them  in  gauze  and  enclosing 
the  whole  in  a  rubber  cot.     The  upper  part  of  the  picture  is  diagrammatic  in  order  to  show  how  the 
radium  tubes  are  attached  to  the  piece  of  sheet  lead. 


as  carefully  prepared  as  for  a  surgical  operation,  is  widel}'  dilated.  If  the  area 
to  be  treated  is  excrescent  the  vaginal  fornices  are  &st  packed  with  gauze  folded 
in  a  narrow  strip.  The  radium  enclosed  in  the  finger  cot  is  then  applied  directly 
against  the  cancerous  area,  the  tail  of  the  finger  cot  extending  toward  the  in- 
troitus.  The  whole  vagina  is  then  closely  packed  with  gauze  so  as  to  keep  the 
radium  firmly  pressed  against  the  cancer  and  to  avoid  any  chance  of  its  slipping 


794 


GYNECOLOGY 


from  its  position.  As  an  additional  preca-ution  against  injury  to  the  posterior 
wall,  which  is  especially  susceptible  to  the  destructive  rays,  we  are  accustomed 
to  fit  a  plate  cut  out  of  several  layers  of  lead  foil  wrapped  in  gauze.  The  gauze 
packing  of  the  vagina  keeps  it  in  place. 

.  This  general  principle  of  application  may  be  modified  in  many  ways  to  suit 
the  exigencies  of  the  case.    When  the  apphcation  is  to  be  made  in  a  cavity  or 


N 


/  /■ 


Jl»;;_;_v«PGrr~ ^ 


Fig.  455. — Application  of  Radium. 

Method  of  applying  radium  to  the  cavity  of  the  uterus.  Two  radium  tubes  are  inserted  tandem 
in  the  end  of  a  long  rubber  tube.  They  are  sewed  in  place.  The  end  of  the  rubber  tubing  reaches 
the  fundus  of  the  uterus.  The  other  end  of  the  tube  is  coiled  in  the  vagina  and  packed  against  the 
cervix  with  gauze.  This  prevents  the  rubber  tube  from  slipping  down  and  exposing  the  cervical 
canal  to  the  action  of  the  rays. 


when  the  radium  tubes  are  to  be  placed  separately  in  order  to  secure  a  cross-fire 
the  tubes  may  be  attached  by  means  of  adhesive  strips  to  pieces  of  sheet  lead 
cut  to  the  required  shape  and  size.  They  are  wrapped  in  gauze  and  tied  in  the 
end  of  a  rubber  finger  cot  as  shown  in  Fig,  454.  If  still  greater  screening  is 
required,  the  silver  tubes  may  be  left  in  the  brass  tubes  in  which  they  are  kept 


OPERATIONS   ON    THE    ABDOMINAL    WALL  795 

and  both  tubes  together  applied  as  described  above.  For  further  details  of 
treatment  see  Part  II  under  Radium  in  the  Treatment  of  Cancer. 

When  radium  is  to  be  used  for  metropathic  cases  a  convenient  technic  is  as 
follows:  Two  tubes  of  radium  are  placed  "tandem"  in  the  end  of  a  long  rubber 
tube.  It  is  better  to  place  two  tubes  of  25  mg.  in  this  manner  than  to  use  a  single 
tube  of  50  mg.,  because  in  this  way  a  more  uniform  application  is  made  to  the 
whole  of  the  endometrial  canal.  It  is  usually  recommended  that  black  rubber 
tubing  be  used  rather  than  the  red,  as  in  the  latter  adventitious  rays  may  be 
set  up.  We  have  had  no  trouble  in  this  respect,  as  we  have  always  used  the 
ordinary  male  rubber  catheter.  The  end  of  the  catheter  which  contains  the 
eye  is  cut  off  and  the  two'tubes  firmly  sewed  in  so  that  they  cannot  possibly  shp 
one  way  or  the  other.  The  other  end  of  the  tube  is  left  long  so  that  when  it  is 
coiled  up  in  the  vagina  it  may  act  as  a  sort  of  spring  to  prevent  its  becoming 
dislocated  from  its  position  in  the  uterus. 

In  applying  radium  to  the  uterine  canal  the  patient  should  always  be  anes- 
thetized. The  end  of  the  rubber  tube  containing  the  radium  is  passed  to  the 
fundus  of  the  uterus.  The  fornices  are  next  packed  with  a  gauze  strip.  The  long 
end  of  the  rubber  tube  is  then  coiled  in  the  vagina  and  made  to  press  against 
the  cervix  by  continuing  the  packing  of  the  vagina  with  the  gauze  strip.  In  this 
way  the  radium  is  prevented  from  slipping  down  into  the  cervical  canal  notwith- 
standing the  movements  of  the  patient. 

The  ends  of  the  gauze  and  of  the  string  attached  to  the  tube  should  be  left 
near  the  introitus  so  that  they  can  be  easily  extracted.  For  further  information 
regarding  the  details  of  treatment  see  Part  II  under  the  section  Radium  in  the 
Treatment  of  Non-malignant  Disease. 


OPERATIONS   ON  THE  KIDNEY 

In  operating  on  kidneys  the  incision  and  proper  exposure  of  the  kidney  is  of 
the  greatest  importance,  for  if  this  is  not  properly  done  the  operation  may  pre- 
sent the  greatest  technical  difficulties.  The  choice  of  the  incision  is  dependent 
upon  the  magnitude  of  the  operation.  For  minor  procedures,  represented  espec- 
ially by  nephrorrhaphy  and  puncture  and  drainage  of  an  abscess,  the  kidney  can 
be  reached  by  separation  of  the  muscle  layers  without  splitting  or  cutting  them; 
while  for  more  extensive  operations,  when  an  enlarged  kidney  must  be  dehvered 
through  the  wound,  the  muscles  must  be  more  or  less  extensively  sectioned. 

MINOR  OPERATIONS 

For  minor  operations,  such  as  suspension,  the  following  technic,  taken  from 
Kelly,  is  recommended: 

The  patient  is  placed  in  the  semiprone  position,  with  an  appropriate  pad, 
so  as  to  expose  the  kidney  region  as  well  as  possible.     One  first  palpates  the 


Fig.  456. — Incision  for  Suspension  and  Minor  Operations  on  the  Kidney. 

regional  landmarks,  which  consist  of  the  twelfth  rib,  the  firm  outer  border  of 
the  sacrospinalis  muscle,  and  the  crest  of  the  ileum  as  far  as  the  anterior  spine. 
The  skin  incision  is  started  somewhat  above  the  middle  of  the  twelfth  rib, 
and  is  curved  downward  and  forward  toward  a  point  midway  between  the  line 

796 


OPERATIONS    ON   THE    KIDNEY 


797 


of  the  spinous  processes  of  the  vertebra  and  the  anterior  superior  spine,  about 
3  inches  in  length.     This  incision  exposes  the  latissimus  dorsi  and  external 


w.^t^Gt- 


i  iG.  457. ^Suspension  of  Kidney. 
Exposure  of  the  latissimus  dorsi  and  external  oblique  muscles  and  the  fat  lying  in  Petit's  triangle 

(adapted  from  Kelly  and  Burnam). 


XcxtiSS  DorsL 


J..  V)TnD<xx  \05.cv<x 


^x\.Ob\vc^oe 


Fig.  458. — Sttspension  of  Kidney. 

Retraction  of  latissimus  dorsi  muscle,  exposing  the  superior  lumbar  trigonum.    The  lumbar  fascia  has 

been  pierced,  allowing  the  retroperitoneal  fat  to  extrude  through  the  opening. 


obhque  muscles,  the  fibers  of  which  meet  each  other  at  a  slight  angle.     At  the 
lower  edge  of  the  retracted  wound  the  muscles  diverge,  leaving  a  small  triangular 


798 


GYNECOLOGY 


fascial  space^the  so-called  Petit's  triangle;  directly  opposite  this  triangle,  at 
the  upper  edge  of  the  wound,  can  be  felt  the  tip  of  the  twelfth  rib  (Fig.  457). 

A  small  retractor  is  then  inserted  so  as  to  draw  back  the  edge  of  the  latissimus 
dorsi.  This  exposes  the  lumbar  fascia  covering  the  area  called  the  "superior 
lumbar  trigonum."  The  lumbar  fascia  is  readily  separated  from  the  overlying 
muscles,  having  only  a  filmy  cellular  connection  with  them.  The  next  step  is 
to  perforate  the  lumbar  fascia  (Fig.  458).     If  the  border  of  the  latissimus  dorsi 


QuoibAuVjmV) 


Y^xWhX 


AQUe' 


lxx\.Ob\. 


Fig.  459. — Suspension  of  Kidney. 

Transverse  incision  through  the  fibers  of  the  latissimus  dorsi  muscle  parallel  to  the  inferior  border  of 

the  last  rib.     Used  when  more  room  is  necessary  (adapted  from  Kelly  and  Burnam). 


muscle  extends  doAvn  too  far,  as  it  sometimes  does,  its  fibers  may  be  cut  trans- 
versely in  the  direction  of  the  vertebral  column. 

The  opening  of  the  lumbar  fascia  is  now  enlarged  by  inserting  two  fingers 
of  each  hand  and  exerting  strong  traction  in  an  up-and-down  direction  (Fig. 
460).  By  this  maneuver,  which  causes  no  injury  to  blood-vessels  or  nerves, 
the  wound  is  readily  made  large  enough  to  insert  the  hand.  The  enlargement 
of  the  wound  brings  to  view  on  its  inner  side  the  border  of  the  quadratus  lum- 


OPERATIONS    ON   THE    KIDNEY 


799 


borum  muscle,  under  the  edge  of  which,  running  parallel  with  its  fibers,  can 
always  be  found  the  first  lumbar  nerve.  The  nerve  is  seen  either  as  a  single  or 
double,  trunk.  It  is  of  great  importance  to  avoid  injuring  this  nerve  either  by 
trauma  or  by  including  it  in  stitches. 

Along  the  upper  margin  of  the  wound,  just  under  the  border  of  the  fascia 
and  running  parallel  with  the  twelfth  rib,  can  be  seen  the  twelfth  subcostal 
nerve  or  one  of  its  branches.     At  the  bottom  of  the  wound  made  by  retraction 


'V 


wn'Srcvx^i^s 


Fig.  460. — Suspension  of  Kidney. 
Enlarging  the  opening  by  traction  with  the  fingers. 


with  the  fingers  is  seen  a  floor  of  fat  of  "orange-yellow  color."  This  fat  layer, 
which  varies  greatly  in  thickness  in  different  individuals,  is  continuous  with  the 
retroperitoneal  fat  of  the  iliac  fossa  and  anterior  abdominal  wall. 

Between  this  retroperitoneal  layer  of  fat  and  the  kidney"  is  another  layer  of 
fat  separated  from  it  by  a  membrane,  the  retrorenal  fascia  (Gerota's  capsule). 
The  last-named  fat  layer  closely  surrounds  the  kidne^^  In  order  to  expose  the 
kidney  this  layer  must  be  opened.     By  gradual  traction  on  the  fatty  capsule 


800 


GYNECOLOGY 


with  pressure  forceps  a  movable  kidney  may  be  drawn  up  to  the  wound.     If 
it  is  desirable  to  deliver  the  kidney,  it  is  best  first  to  separate  it  entirely  from 'its 
fatty  capsule  by  the  hand.     Only  a  movable  kidney  can  safely  be  dehvered 
through  the  incision  just  described. 

SUSPENSION  OF  THE  KIDNEY  (KELLY'S  TECHNIC) 

The  incision  is  made  in  the  manner  described  above  for  minor  operations. 
If  the  patient  has  been  properly  placed  on  the  table,  with  a  pad  under  the  loin, 


LaU^^IlipYSv-  5i^^\it^ 


"HtXvo^ecvt. 
Tat- 


Ou\\\nt  oC  V\\^x\€  j-'/ 


>   \ 


Fig.  461. — Suspension  of  Kidney. 
The  latissimus  dorsi  has  been  cut  transversely.     The  retroperitoneal  fat  has  been  opened  and  the 
perirenal  fat  grasped  with  forceps.     Traction  of  the  perirenal  fat  has  brought  the  upper  pole  of  the 
kidney  into  view  (adapted  £rom  Kelly  and  Burnam). 

the  movable  kidney  is  forced  upward  under  the  ribs,  so  that  in  bringing  it  into 
view  it  must  be  drawn  downward  rather  than  upward.     The  kidney  is  brought 


OPERATIONS    ON   THE    KIDNEY 


801 


into  view  by  attaching  several  clamps  to  the  fatty  capsule  and  exerting  careful 
traction  so  as  not  to  tear  the  fat.  In  order  to  expose  a  space  for  the  insertion 
of  stitches  the  capsule  is  stripped  from  the  posterior  surface  and  upper  pole  of 
the  kidney. 

The  kidney,  without  being  delivered,  is  then  thoroughly  palpated  to  discover 
any  incidental  abnormality. 


Fig.  462. — Suspension  of  Kidney. 
Introduction  of  the  Brodel  suture  (adapted  from  Kelly  and  Burnam). 

In  placing  the  stitches  for  suspension  the  object  in  view  is  to  create  an  arti- 
ficial adhesion  between  the  capsule  of  the  kidney  and  the  muscle  with  which  it 
i&  to  lie  in  contact.  This  can  best  be  accomplished  with  a  non-absorbable  stitch, 
either  of  linen  or  silk,  preferably  the  latter. 

As  to  the  level  at  which  the  kidney  should  be  suspended,  Kelly  advocates 

51 


802 


GYNECOLOGY 


attaching  it  as  high  as  possible,  and  our  experience  substantiates  this  advice. 
If  the  kidney  can  be  made  to  recede  above  the  twelfth  rib  the  external  obhque 
muscle  is  strongly  retracted  or,  if  necessary,  cut,  and  the  tissues  dissected 
back  until  the  twelfth  rib  is  exposed. 

Three  stitches  of  fine  silk  are  to  be  used  for  suspending  the  kidney.    They 
are  placed  in  a  line  along  the  outer  border  of  the  kidney,  the  upper  one  at  the 


Fig.  463. — Suspension  or  Kidney. 
Placing  of  the  Brodel  stitches  (adapted  from  Kelly  and  Burnam). 


junction  of  the  upper  and  middle  thirds,  the  lower  one  at  the  lower  pole,  and  the 
third  halfway  between  these  two.  The  upper  stitch  is  applied  first,  and  is  de- 
signed to  anchor  the  upper  pole  of  the  kidney  to  the  twelfth  rib.  The  suture  is 
first  threaded  on  a  large  curved  needle,  which  carries  the  suture  from  a  point 
just  above  the  twelfth  rib  through  the  wall,  emerging  in  the  wound  close  to 
the  kidney.  The  needle  is  then  changed  to  a  fine  full-curved  needle,  and  the 
suture  in  the  kidney  taken  at  the  junction  of  the  upper  and  middle  thirds.     The 


OPERATIONS    ON   THE    KIDNEY  803 

manner  of  applying  the  stitch  was  devised  by  M.  Brodel,  and  consists  in  plaiting 
it  into  the  kidney  substance  at  three  points  of  a  small  triangle,  so  that  a  maximum 
of  tensile  strength  is  achieved  without  danger  of  lacerating  the  capsule.  The 
stitch  is  completed  by  again  threading  it  on  the  large  needle  and  carrying  it 
back  to  a  point  above  the  twelfth  rib,  near  that  from  which  it  started.  The 
second  stitch  is  passed  in  a  similar  manner  through  the  quadratus  muscle  at  the 
lower  pole  of  the  kidney,  care  being  taken  not  to  injure  or  include  the  first 
lumbar  nerve  which  runs  just  under  the  lower  edge  of  the  muscle.  It  should 
always  be  identified  before  placing  the  stitch.  The  third  suture  is  applied  in 
the  quadratus  muscle  between  the  two  already  placed. 

In  using  the  Brodel  stitch  it  should  not  be  carried  deeply  into  the  kidney 
substance.  Before  tying  the  suspensory  sutures  care  should  be  taken  that  any 
of  the  fatty  capsule  intervening  between  the  kidney  capsule  and  the  muscle 
be  cleaned  away,  for  its  presence  prevents  the  formation  of  an  adequate 
suspensory  adhesion.  The  redundant  fat  of  the  capsule  may  be  removed  or 
stitched  to  the  quadratus  muscle.  The  wound  is  closed  in  layers  without 
drainage.     If  the  latissimus  dorsi  has  been  cut,  its  fibers  are  sewed  together. 

INCISION  FOR  MAJOR  OPERATIONS  ON  THE  KIDNEY 

When  the  proposed  operation  is  to  involve  delivery  and  removal  of  the 
kidney  it  is  of  great  importance  to  have  a  generous  opening  to  avoid  embar- 


Fig.  464. — Nephrectomy.     The  Incision. 

passing  difficulties  and  dangerous  accidents.  For  this  purpose  a  long  incision 
is  necessary.  As  in  making  the  incision  for  suspension,  one  must  first  determine 
the  location  of  the  twelfth  rib,  the  outer  border  of  the  sacrospinalis  muscles,  and 
the  curve  of  the  iliac  crest  as  far  as  the  anterior  superior  spine.      Within  the 


804 


GYNECOLOGY 


angle  made  by  the  twelfth  rib  and  the  muscle  border  is  an  area  which  is  softer 
to  the  feel  than  the  surrounding  parts,  and  it  is  in  this  area  that  the  incision 
starts.  It  is  then  carried  in  a  curving  sweep  toward  the  anterior  superior 
spine,  the  length  of  the  incision  being  determined  by  the  magnitude  of  the  opera- 
tion. The  muscular  structures  covering  the  kidney  may  be  opened  in  a  variety 
of  ways. 

The  superior  lumbar  triangle  may  be  first  exposed  and  a  blunt  opening  of 
the  lumbar  fascia  made  in  the  manner  described  for  minor  operations.     This 


\vi\*.Gvcv\ies 


Fig.  465. — Nephrectomy. 
The  fibers  of  the  external  oblique  muscle  are  being  divided  preparatory  to  making  the  "frying  pan" 

incision. 


wound  may  then  be  greatly  enlarged  by  cutting  downward  in  the  direction  of 
the  anterior  superior  spine  across  the  abdominal  muscles  (external  oblique, 
internal  oblique,  trans versalis)  and  by  cutting  upward  across  the  latissimus 
dorsi  and  the  inferior  serratus  posticus  muscles.  Or  the  muscular  structures 
may  be  cut  before  opening  the  lumbar  fascia  (Fig.  467). 

Still  another  method  is  the  "frying  pan"  incision  of  Kelly.  A  long  skin  in- 
cision is  made.  The  abdominal  muscles  are  first  opened  by  splitting  the  fibers, 
as  in  McBurney's  operation  for  appendicitis.  The  wound  is  stretched  with 
the   fingers   as   in   Fig.  460).     An   incision   from   this   opening  is  then  made 


OPERATIONS    ON   THE    KIDNEY 


805 


upward  through  the  muscles  in  the  direction  of  the  upper  angle  of  the  wound 
(Fig.  466). 

When  the  lumbar  fascia  is  opened  the  retroperitoneal  fat  leaps  into  view,  while 
at  the  posterior  angle  can  be  seen  the  border  of  the  quadratus  lumborum  with 
the  first  lumbar  nerve  (ileohypogastric)  skirting  along  beneath  its  lower  edge. 
Division  of  this  fat  brings  one  to  the  thin  fascial  layer  of  Gerota's  capsule,  division 


^^e>xayes 


Fig.  466 — Kelly's  "Frying  Pan"  Incision  for  Nephrectomy. 
The  fibers  of  the  external  oblique  nluscle  have  been  separated.     The  incision  is  carried  across 
the  muscles  to  the  upper  angle  of  the  wound.     The  underlying  layers  of  muscle  are  treated  in  the 
same  way. 

of  which  reveals  the  lemon-yellow  fat  of  the  true  fatty  capsule  of  the  kidney. 
It  is  not  always  easy  to  distinguish  the  two  layers  of  fat  and  Gerota's  capsule. 
Care  should  be  taken  in  making  the  opening  through  the  surrounding  layers  to 
avoid  entering  the  peritoneal  cavity  or  injuring  the  cecum  which  lies  imme- 
diately in  front  of  and  intimately  associated  with  the  outside  fat  layer.  This 
can  be  done  by  keeping  well  back  toward  the  quadratus  muscle. 


806 


GYNECOLOGY 


VI ^.G-.  a^-ttvlM<. 


Fig.  467. — Nephrectomy. 
Diagram  showing  the  muscles  that  are  divided  before  opening  the  lumbar  fascia:  a,  Serratus 
posticus  inferior;  h,  latissimus  dorsi;    c,  external  oblique;  d,  internal  oblique;  e,  sacrolumbalis;  /, 
lumbar  fascia;  g,  transversalis. 


ln\.OU 


\umb 


X  0\d\. 


3-Uo-Ui.ai.Xev-u'i 


^va<vs«i(i:,v^a\".c^ 


Fig.  468.. — Nephrectomy. 
Exposure  of  the  fat  capsule. 


OPERATIONS    ON   THE    KIDNEY 


807 


When  the  fatty  capsule  has  been  divided,  the  firm,  smooth  surface  of  the 
kidney  can  be  felt.  Clamps  are  put  on  the  fat  to  draw  the  kidney  up  toward 
the  wound  and  facilitate  the  next  step,  which  is  to  separate  the  fatty  capsule  and 
deliver  the  kidney. 

The  capsule  is  methodically  peeled  off  by  the  finger,  the  anterior  and  poste- 
rior surfaces  being  first  freed  with  little  trouble.  In  freeing  the  upper  pole  the 
capsule  is  normally  more  adherent,  and  if  inflammatory  disease  is  present 
serious  difficulty  may  be  encountered.     It  is  important  that  the  finger  be  kept 


Fig.  469.' — Nephrectomy. 
Division  of  the  ureter  with  cautery. 


close  to  the  kidney  surface  in  order  not  to  injure  the  colon  or  duodenum,  which 
lie  in  close  proximity. 

The  lower  pole  is  usually  easily  freed.  When  the  kidney  has  been  thor- 
oughly disengaged  from  its  surrounding  capsule  of  fat  the  next  step  is  to  expose 
and  sever  the  ureter.  The  lower  pole  is  first  hfted  out  of  the  wound,  so  that  the 
kidney  is  turned  into  the  position  of  anteversion  (Albarran).  This  can  easily 
be  done  if  the  upper  pole  has  been  well  freed.  By  separating  the  fat  in  the 
depth  of  the  wound  just  below  the  lower  pole  the  ureter  ordinarily  comes 
readily  into  view.     If,  however,  the  ureter  cannot  at  first  be  found,  it  is  to  be 


808 


GYNECOLOGY 


sought  in  front  in  relation  with  the  peritoneum  and  not  behind  near  the  psoas 
muscle.  When  the  ureter  has  been  found  it  is  stripped  of  the  surrounding  fat 
for  a  short  distance,  tied  in  two  places,  and  severed  by  the  cautery. 

When  the  ureter  has  been  cut,  the  kidney  pelvis  must  then  be  developed, 
and  this  should  be  thoroughly  done,  otherwise  a  portion  of  its  wall  may  be  in- 
cluded later  in  clamping  the  pedicle,  the  cutting  of  which  may  cause  spilUng  of 
urine  in  the  wound. 


?!?. 


\\l!^Q3va\i^iS- 


Fig.  470. — Nephrectomy. 
Clamping  and  tying  the  renal  vessels. 


After  the  pelvis  has  been  thoroughly  freed,  all  remaining  adhesions  of  the 
kidney  are  released,  and  the  fat  about  the  vessels  pushed  back  so  as  to  expose 
them  more  clearly.  The  kidney  is  dehvered  completely  from  the  wound,  the 
forefinger  of  the  left  hand  bringing  into  view  the  pedicle.  The  pedicle  musf  be 
tied  with  the  greatest  care.  A  convenient  method  is  to  pass  a  double  ligature 
into  the  pedicle  with  a  blunt  needle.  The  tension  on  the  kidney  is  then  slack- 
ened and  the  hgatures  tied  as  far  away  from  the  kidney  as  possible.      A  clamp 


OPERATIONS    ON   THE    KIDNEY  809 

is  then  applied  outside  of  the  ligatures  and  the  pedicle  cut  between  the  clamp 
and  the  kidne^^  The  clamp  insures  against  the  retraction  of  the  stump  and 
controls  bleeding  if  the  first  ligatures  were  not  adequate.  It  is  well  now  to 
reinforce  the  first  ligatures  by  one  including  the  entire  stump. 

Drainage  following  nephrectomy  depends  on  the  nature  of  the  case  and 
follows  the  rules  for  drainage  elsewhere. 

The  wound  is  sewed  in  layers,  the  severed  muscle  ends  being  carefully  ap- 
proximated. If  the  patient  is  in  shock  and  it  is  important  to  save  time,  the 
wound  can  be  closed  with  through-and-through  silkworm-gut  sutures. 


OPERATIONS   ON  THE   URETERS 

To  the  gynecologist  surgery  of  the  ureters  is  of  chief  interest  in  so  far  as  it 
relates  to  the  repair  of  injuries  clone  to  the  ureter  during  complicated  pelvic 
operations.  The  ureters  are  most  frequently  injured  during  the  extended  opera- 
tions for  cancer  and  during  the  extirpation  of  intraligamentous  tumors  of  the 
uterus  or  ovaries,  which  in  the  process  of  growth  dislocate  the  ureters  from  their 
normal  position.  The  injuries  to  which  the  ureters  are  exposed  during  these 
operations  are  cutting,  either  partially  or  completely,  ligation  with  partial  or 
complete  obstruction  of  the  lumen,  and  pressure  from  clamps,  with  consequent 
necrosis  and  sloughing  of  the  ureteral  wall.  Another  not  infrequent  injury  is 
the  result  of  stripping  the  ureter  of  its  blood-supply  so  that  necrosis  follows. 

Cutting  of  the  ureter  is  usually  recognizable  at  once  and  demands  imme- 
diate attention.  The  other  accidents  are  often  not  discovered  until  later. 
Ligature  of  both  ureters  results  in  death.  Ligature  of  one  ureter  may,  if  the 
ligature  completely  and  permanently  occludes  the  ureter,  often  result  in  cessa- 
tion of  function  and  atrophy  of  the  corresponding  kidney.  If  the  obstruction 
is  incomplete,  as  is  more  frequently  the  case,  there  is  hkelihood  of  hydro-  or 
pyonephrosis,  which  necessitates  a  later  extirpation  of  the  kidney.  If  the  ureter 
has  been  accidentally  clamped  during  the  operation,  local  necrosis  is  very  prob- 
able, with  extravasation  of  urine,  in  which  case  death  ensues  unless  provisional 
drainage  was  established  at  the  time  of  the  operation.  Sloughing  of  the  ureter 
results  in  fistula  through  the  vagina  if  there  is  drainage.  The  same  may  be 
said  of  necrosis  caused  by  stripping  the  ureter  of  its  blood-supply.  ^ 

When  the  ureter  has  been  cut  during  an  operation  the  surgeon  has  before 
him  four  procedures  from  which  to  choose:  (1)  Uretero-ureterostomy  (or 
ureterocystostomy) ;  (2)  extirpation  of  the  kidney;  (3)  ligation  of  the  proximal 
end  of  the  ureter;  (4)  establishment  of  a  ureteral  fistula. 

(1)  Uretero-ureterostomy. — When  the  injury  of  the  ureter  has  taken  place 
at  such  a  distance  from  the  bladder  that  the  proximal  end  cannot  be  conveniently 
implanted  in  the  bladder  wall,  an  anastomosis  between  the  severed  ends  of  the 
ureter  is  indicated.  This  is  best  accomplished  by  implanting  the  proximal  end 
of  the  ureter  into  the  side  of  the  distal  end.  The  distal  end  is  first  firmly  tied. 
In  the  side  is  then  made  a  longitudinal  slit  large  enough  to  admit  freely  the 
other  end  of  the  ureter.  A  fine  linen  or  catgut  suture,  threaded  on  a  fine  rounded 
needle,  is  placed  as  depicted  in  Fig.  471.  It  first  enters  the  distal  portion  of 
the  ureter  from  without  inward  at  a  point  just  below  the  lower  end  of  the  slit. 
It  then  is  carried  to  the  proximal  end  of  the  ureter  and  enters  the  wall  from 
within  outward  at  a  short  distance  from  the  end.      Entering  the  proximal  and 

810 


OPERATIONS    ON   THE    URETERS 


811 


distal  walls  in  the  reverse  direction,  it  emerges  close  to  the  point  from  which 
it  was  started.  With  the  aid  of  this  suture  the  proximal  end  of  the  ureter  is 
drawn  into  the  slit  made  in  the  distal  portion  and  anchored  there  by  tying  the 
suture.  Another  suture  of  fine  linen  fastens  the  posterior  side  of  the  enter- 
ing portion  of  the  ureter  to  the  upper  angle  of  the  sht.  In  order  to  make  the 
union  more  secure  two  or  three  more  sutures  may  be  taken  around  the  line  of 
junction. 


Fig.  471. — Ureteral  Anastomosis  (End  to  Side;. 
The  distal  end  of  the  ureter  is  tied  and  a  longitudinal  incision  made  in  the  wall  near  the  tied 
end.     The  manner  of  placing  the  principal  suture  is  shown   (magnified  for  purposes  of  illustra- 
tion) . 

The  end-to-side  anastomosis  just  described  is  the  best  method  if  the  ends 
of  the  cut  ureter  are  long  enough  to  admit  of  the  manipulation  without  too 
much  traction  and  without  too  much  interference  with  the  ureteral  blood-supply. 
When  the  ends  are  too  short  for  the  previous  operation  an  end-to-end  anas- 
tomosis may  be  performed  in  the  manner  shown  in  Fig.  473.  The  distal  end 
is  incised  a  short  distance  in  order  that  it  may  admit  the  end  of  the  other 
portion.  A  guichng  stitch  is  placed  in  the  same  manner  as  in  the  previous 
operation,  and  the  union  of  the  two  ends  made  secure  by  interrupted  sutures 


Fig.  472. — Ureteral  Axastomosis  (Ent)  to  Side). 
Operation  completed. 


of  fine  linen.  It  is  probable  that  this  form  of  anastomosis  is  less  secure  than 
the  one  first  described,  and  is  also  more  likely  to  result  in  stricture  of  the  canal. 
When  either  of  these  operations  has  been  done,  provisional  drainage  should 
be  established  in  case  of  leakage.  This  can  in  most  cases  be  done  through  the 
vagina.  The  drain  should  be  as  small  as  possible,  encased  in  rubber,  and  nevei^ 
in  contact  with  the  ureteral  wound.  It  should  be  so  placed  that  if  leakage  does 
occur  it  will  find  a  path  of  least  resistance  to  the  drain.  The  drainage,  of  course, 
is  subperitoneal. 


812 


GYNECOLOGY 


Ureterocystanastomosis. — When  the  lesion  of  the  ureter  occurs  near  enough 
to  the  bladder  to  allow  the  proximal  end  to  be  easily  approximated  to  the  blad- 


FiG.  473. — Ureteral  Anastomosis  (End  to  Exd). 
Manner  of  placing  the  principal  suture. 

der,  implantation  in  the  bladder  wall  is  indicated.     The  implantation  can  be 
done  intraperitoneally  or  extraperitoneally,   the  latter  being  far   preferable. 


Fig.  474. — Ureteral  Anastomosis  (End  to  End). 
Operation  completed. 


This  is  usually  a  very  simple  matter,  for  the  portion  of  the  bladder  nearest  the 
point  of  injury  has  been  denuded  of  peritoneum  during  the  process  of  the  main 
operation. 


Fig.  475. — tUreterovesical  Traxsplaxtation. 
Showing  method  of  slitting  up  the  end  of  the 
ureter  and  placing  the  sutures. 


Fig.  476. — Ureterocystanastomosis. 
Operation  completed  (diagrammatic). 


The  operation  devised  by  Sampson  is  the  simplest  and  most  effective.  A 
small  slit  is  made  in  the  end  of  the  ureter.  In  the  wall  of  the  bladder  is  made  a 
small  incision  large  enough  to  admit  the  end  of  the  ureter.     The  making  of  this 


OPERATIONS    ON    THE    URETERS  813 

incision  is  facilitated  by  having  an  assistant  insert  a  catheter -into  the  bladder 
through  the  urethra,  so  that  the  end  of  the  catheter  may  be  used  as  a  point  of 
counter-resistance.  Sutures  of  fine  linen  or  catgut  are  then  placed  in  the  two 
lips  of  the  ureteral  end  and  the  bladder  in  the  way  shown  in  Fig.  475.  The 
placing  of  these  sutures  is  made  easier  by  threading  a  needle  on  each  end.  The 
split  end  of  the  ureter  is  drawn  into  the  bladder  by  traction  on  the  two  sutures. 
The  sutures  are  then  tied.  If  the  opening  in  the  bladder  has  been  made  some- 
what too  large,  a  few  fine  sutures  may  be  apphed  in  order  to  make  the  joint 
secure. 

Kronig  has  still  further  simplified  Sampson's  operation  by  sewing  only  one 
of  the  hps  of  the  spUt  end  of  the  ureter  into  the  bladder  wall.  He  reports  23 
successful  cases  out  of  25. 

EXTIRPATION  OF  THE  KIDNEY 

One  can  imagine  cases  in  which  anastomosis  of  the  ureter  is  impossible  after 
injuring  the  ureter.  One  of  the  alternatives  open  to  the  surgeon  is  nephrectomy. 
This  can  be  done  transperitoneallj^  through  the  same  wound  made  for  the  pelvic 
operation,  though  it  maj^  have  to  be  enlarged  upward  somewhat.  The  condi- 
tion of  the  other  kidney  is  first  determined  and  all  possible  doubt  of  its  proper 
function  excluded.  In  performing  the  operation  the  colon  is  pushed  toward 
the  median  fine  and  an  incision  made  through  the  parietal  peritoneum.  The 
perirenal  fat  capsule  is  divided  and  cleared  away  to  gain  complete  exposure 
of  the  renal  vessels,  pelvis,  and  ureter.  The  ureter  is  then  divided,  the  pelvis 
lifted  from  its  bed,  and  the  renal  vessels  developed  and  tied  with  as  long  a  pedicle 
as  possible. 

Extirpation  of  a  normal  kidney  through  an  abdominal  wound  is  not  a  diffi- 
cult operation;  nevertheless,  it  should  not  be  undertaken  unless  the  patient  is  in 
excellent  condition  or  unless  the  main  operation  has  not  been  prolonged.  As 
neither  of  these  conditions  usually  prevail  at  the  end  of  a  difficult  operation  for 
uterine  cancer,  in  which  operation  the  ureter  is  most  commonlj-  injured,  imme- 
chate  nephrectomy  is  a  procedure  which  is  not  often  resorted  to. 

LIGATION  OF  THE  PROXIMAL  END  OF  THE  URETER 

WTien  the  injury  to  the  ureter  is  such  that  anastomosis  is  out  of  the  question 
and  nephrectomy  is  too  grave  an  operation  to  be  considered,  the  proximal  end 
of  the  ureter  may  be  tied,  on  the  chance  that  the  corresponding  kidnej^  will 
cease  to  functionate  and  become  atrophied.  This  should,  of  course,  not  be 
done  if  there  is  any  doubt  regarding  the  integrity  of  the  opposite  kidney. 

The  success  of  this  maneuver  depends  to  a  considerable  extent  on  the  fate 
of  the  hgature  apphed  to  the  ureter.  If  it  cuts  into  the  ureteral  wall  it  may 
cause  a  fistula,  or  if  it  becomes  infected,  ascending  infection  of  the  kidney  will 
ensue,  in  either  of  which  cases  a  nephrectomy  will  eventually  be  required. 


814  GYNECOLOGY 

If,  however,  great  care  is  exercised  in  closing  the  end  of  the  ureter  a  suc- 
cessful outcome  may  be  expected. 

In  a  case  operated  on  by  the  author  the  left  ureter  was  involved  in  a  colossal  adherent 
cystic  myoma  of  the  uterus,  so  that  it  had  to  be  resected  above  the  brim  of  the  pelvis  and  at 
its  entrance  into  the  bladder.  The  proximal  end  of  the  ureter  was  carefuUy  tied  and  sutured 
over.  The  patient  had  complete  suppression  of  iirine  for  thu'ty-six  hours,  when  she  began  to 
secrete  urine,  and  from  then  on  made  an  uneventful  recovery.  The  right  kidney  underwent  a 
compensatory  hypertrophy  which  could  be  felt  on  palpation  several  years  after  the  operation. 
The  patient  was  in  perfect  health. 


FORMATION  OF  URETERAL  FISTULA 

When  the  ureter  has  been  injured  so  that  anastomosis  is  impossible  and  the 
opposite  kidney  is  in  any  way  incompetent,  the  only  course  left  for  the  surgeon 
is  to  establish  a  fistula  by  carrying  the  ureter  through  the  muscle  layers  of  the 
back  and  attaching  it  at  an  opening  in  the  skin.  Fortunately,  it  is  only  ex- 
tremely rare  that  the  combination  of  circumstances  would  make  this  undesir- 
able operation  necessary. 

Implantation  of  the  ureter  in  the  colon  is  also  an  operation  to  be  avoided  if 
possible,  as  it  ahnost  inevitably  results  in  an  ascending  infection  of  the  kidney. 


OPERATIONS   ON  THE   BLADDER 


SUPRAPUBIC  CYSTOTOMY 


In  opening  the  bladder  from  above  the  technic  described  by  Kelly  is  recom- 
mended. The  patient  is  preferably  under  complete  anesthesia.  A  catheter  is 
first  introduced  into  the  bladder  and  the  bladder  thoroughly  washed  out.  The 
catheter  is  left  in  the  bladder  for  the  later  introduction  of  air.  A  transverse  or 
longitudinal  incision  is  made  just  above  the  pubes,  the  fascia  divided,  and  the 
recti  muscles  held  apart.  The  suprapubic  retroperitoneal  space  is  now  cleared 
by  dissection  with  the  fingers,  care  being  taken  not  to  rupture  the  peritoneum. 
An  assistant  then  attaches  a  sterilized  Davidson  syringe  to  the  catheter  and 
pumps  air  into  the  bladder  until  it  balloons  up  into  the  suprapubic  wound. 
The  bladder  wall  is  caught  either  by  two  sutures  or  by  two  fine  Alhs'  clamps 
to  serve  as  tractors.  The  bladder  wall  is  freed  by  blunt  dissection,  which 
pushes  the  peritoneum  further  back  out  of  harm's  way,  care  being  taken  not  to 
strip  the  bladder  wall  over  an  unnecessary  area. 

The  bladder  is  opened  by  an  incision  made  transversely  or  longitudinally 
between  the  two  tractors.  When  the  opening  through  the  mucosa  is  made  the 
air  escapes  and  the  bladder  collapses.  The  patient  is  then  placed  in  the  Tren- 
delenburg position,  the  bladder  being  now  well  exposed  for  whatever  operation 
is  intended. 

In  closing  the  wound  a  fine  chromic  catgut  stitch  is  used,  carried  through 
the  vesical  wall  down  to  the  mucosa.  Two  or  three  layers  should  be  used  so  as 
to  invert  the  wound  toward  the  bladder.  Especial  care  should  be  taken  in 
uniting  the  fibrous  fascia  layer  of  the  outer  vesical  wall. 

The  recti  muscles,  fascia,  and  skin  are  approximated  in  the  usual  way. 
Kelly  recommends  leaving  a  small  drain  in  the  wound  of  the  abdominal  wall. 

VAGINAL  CYSTOSTOMY 

In  severe  cases  of  chronic  cystitis,  especially  those  due  to  tuberculosis  or 
long-continued  irritation  from  stone,  opening  of  the  bladder  and  drainage  through 
the  vagina  gives  immense  relief.  Dudley's  technic  in  performing  this  operation 
is  first  to  distend  the  bladder  with  water,  the  patient  being  under  general  anes- 
thesia in  the  dorsal  position.  A  pair  of  curved  artery  forceps  is  introduced 
into  the  bladder  and  the  ends  separated.  An  incision  is  then  made  between 
them  into  the  bladder  (Fig.  477),  care  being  taken  not  to  cut  the  structures  at 
the  neck  of  the  bladder.     The  incision  is  |  to  1  inch  long  and  should  be  large 

815 


816 


GYNECOLOGY 


enough  to  insure  competent  drainage.  There  need  be  no  fear  that  there  will 
be  later  trouble  in  closing  the  fistula.  The  chief  difficulty  is  in  keeping  these 
fistulas  open,  and  for  that  reason  the  additional  precaution  must  be  taken 
after  making  tie  incision  of  sewing  the  bladder  mucosa  to  the  vaginal  mu- 
cous membrane.  If,  after  the  lapse  of  time,  it  becomes  desirable  to  close  the 
wound,  and  it  is  still  open,  an  ordinary  vesicovaginal  operation  is  practically 


Fig.  477. — Vaginal  Cystostomt, 
A  pair  of  half-length  curved  clamps  is  introduced  into  the  bladder  through  the  urethra  and 
partly  opened.      An  incision  is  made  through  the  vaginal  and  bladder  walls  between  the  ends  of  the 
clamps  (adapted  from  Kelly  and  Burnam).^ 


sure  to  be  successful.  In  this  case  the  conditions  differ  from  the  fistulas  that 
follow  childbirth  in  which  the  vesicovaginal  septum  has  suffered  a  loss  of  tissue, 
so  that  the  operation  of  closure  is  hampered  by  the  tension  of  the  wound  edges. 
In  nulhpara,  in  whom  the  perineum  acts  as  an  obstruction  to  full  drainage, 
Kelly  recommends  enlarging  the  introitus  by  incising  the  peritoneum  and 
sewing  the  vaginal  mucous  membrane  to  the  skin  transversely,  as  in  Fig.  294. 


OPERATIONS   ON  THE  RECTUM 


PROLAPSE  OF  THE  RECTUM 


The  treatment  of  prolapse  of  the  rectum  depends  on  whether  the  condition 
is  one  merely  of  prolapse  of  the  mucous  membrane,  such  as  is  frequently  seen  in 
children,  or  whether  it  is  a  so-called  true  prolapse  in  which  all  the  layers  of 
the  rectal  wall  are  involved. 

When  the  prolapse  is  of  the  mucous  membrane  only,  conservative  measures 
should  be  employed  as  far  as  possible.  Many  of  these  cases,  especially  in  children, 
are  the  result  of  inflammation  of  the  rectal  mucosa,  and  can  be  cured  by  local 
apphcations  to  treat  the  catarrh.  Mechanical  supports  are  sometimes  effica- 
cious, as  are  also  electricity  and  massage  by  the  Thure  Brand  method. 

Of  operative  measures  for  treating  true  prolapse  there  are  a  great  number, 
a  few  of  which  may  be  mentioned.  The  canal  may  be  narrowed  by  longitudinal 
resections  of  the  mucous  membrane  with  suture  of  the  wounds.  This  is  also  done 
by  resecting  the  coccyx,  and  through  the  opening  thus  made  the  rectal  wall  is 
infolded  longitudinally  and  then  attached  to  the  sacrum  (Marchant).  The 
rectum  may  be  suspended  in  another  and  simpler  way:  A  transverse  incision 
is  made  posterior  to  the  anus.  Through  this  incision  the  posterior  wah  of  the 
rectum  is  separated  from  its  attachments  toward  the  coccyx  and  sacrum.  With 
the  finger  in  the  rectum,  the  posterior  wall  can  be  delivered  through  the  opening 
behind  the  anus,  ready  for  the  apphcation  of  sutures.  Several  non-absorbable 
sutures  (preferably  silkworm-gut)  are  then  passed  through  the  skin  on  one  side 
of  the  sacrum  into  the  wall  of  the  rectum,  and  then  out  past  the  other  side  of 
the  sacrum.  The  sutures  are  introduced  into  the  rectum  where  it  is  delivered 
through  the.  incision,  so  that  there  is  no  danger  of  carrjdng  them  too  far  into 
the  wall.  When  the  sutures  are  tied  ovev  the  sacrum  the  slack  wall  of  the 
rectum  is  drawn  strongly  upward  and  attached  to  the  sacrum.  The  transverse 
incision  is  closed  with  the  exception  of  a  small  rubber  drain.  The  silkworm-gut 
sutures  are  removed  in  about  ten  days.  We  have  used  this  operation  with  suc- 
cess, but  in  one  case  the  convalescence  was  delayed  by  troublesome  sepsis  in  the 
wound.     The  operation  is  Tuttle's  modification  of  Ekehorn's  method. 

Other  methods  of  suspension  of  the  rectum  are  carried  out  by  the  abdominal 
route.  Most  of  these  procedures  are  based  on  the  principle  of  suspending  the 
rectum  or  sigmoid  to  the  anterior  abdominal  wall,  a  procedure  that  is  very  ob- 
jectionable from  a  surgical  standpoint. 

,    The  most  logical  abdominal  operation  for  prolapse  is  that  devised  by  Moscho-' 
witz,  who  proceeds  on  the  interesting  and  reasonable  theory  that  true  rectal 

52  817 


818 


GYNECOLOGY 


prolapse  is  a  sliding  hernia.  On  account  of  the  adherence  of  the  peritoneum  to 
the  anterior  wall  of  the  rectum  there  is  no  peritoneal  sac  as  in  other  hernias. 
The  sliding  process  takes  place  first  in  the  anterior  wall  of  the  rectum  which  is 
free,  the  posterior  wall  being  intimately  attached  to  the  pelvis.  Complete  pro- 
lapse of  the  entire  circumference  of  the  gut  takes  place  only  in  late  stages  of  the 


\v(.T?G<-£\\ies~: 


Fig.  478. — Mqschowitz's  Operation  for  Prolapse  of  the  Rectum. 
The  uterus  and  rectum  are  drawn  upward  toward  the  wound,  exposing  Douglas'  fossa.    Purse- 
string  sutures  are  introduced  around  the  circumference  of  the  fossa  beginning  at  the  deepest  part. 
Only  two  sutures  are  shown  in  the  drawing.     Five  or  six  are  usually  required  to  complete  the  opera- 
tion.    When  the  stitches  are  drawn  taut  the  fossa  is  completely  obliterated. 


disease.  In  most  cases,  therefore,  only  the  anterior  wall  is  found  involved. 
The  pouch  of  Douglas  naturally  follows  this  prolapse,  and  for  this  reason  loops 
of  intestine  are  frequently  found  in  the  hernial  protrusion. 

The  technic  of  Moschowitz's  operation  is  as  follows:  A  long  median  incision, 
with  the  patient  in  extreme  Trendelenburg  position.  The  culdesac  of  Douglas 
is  always  found  unusually  deep.     The  rectum  is  pulled  up  and  held  taut.     Linen 


OPERATIONS    ON   THE    RECTUM  819 

or  silk  sutures  are  now  passed  circularly  around  the  culdesac  of  Douglas,  the 
lowest  suture  being  placed  about  1  inch  above  the  lowest  point  of  the  pouch. 
About  five  or  six  sutures  are  placed  one  above  the  other,  so  that  when  drawn 
taut  they  completely  obhterate  the  culdesac. 

When  the  sutures  reach  the  region  of  the  supravaginal  portion  of  the  cervix 
and  body  of  the  uterus  they  include  the  muscular  tissue  of  these  structures.  It 
is  important  to  avoid  injuring  the  ureters  and  the  internal  ihac  vessels. 

The  after-treatment  is  the  same  as  that  of  any  pelvic  operation.  The 
bowels  are  left  to  move  of  themselves. 

HEMORRHOIDS 

The  three  principal  surgical  procedures  for  the  treatment  of  hemorrhoids 
are  AlHngham's  dissection  and  hgation  of  the  hemorrhoidal  artery.  White- 
head's radical  removal  of  the  hemorrhoidal  tissue,  and  the  clamp  and  cautery 
operation. 

By  far  the  most  rational  and  useful  of  these  operations  is  the  method  of 
dissection  and  hgation.  With  the  patient  in  the  perineal  position,  the  sphincter 
is  first  thoroughly  but  not  injudiciously  dilated  (Fig.  479).  The  hemorrhoids 
are  thus  brought  prominently  into  view.  The  most  conspicuous  ones  are  then 
removed  in  the  following  manner: 

The  most  sahent  part  of  the  hemorrhoid  is  seized  with  an  artery  clamp  and 
lifted  up.  The  mucous  membrane  over  the  hemorrhoid  is  incised  by  a  narrow 
oval  incision,  including  the  part  seized  by  the  clamp  and  running  in  a  radiating 
direction  with  reference  to  the  anus  (Fig.  480). 

When  the  incision  through  the  membrane  has  been  made,  the  pile  is  still 
further  freed  with  a  few  snips  of  the  scissors  until  the  pedicle  containing  the 
artery  is  reached.  This  is  tied  with  fine  catgut,  leaving  the  pedicle  rather 
long  (Fig.  481),  It  is  important  not  to  remove  too  much  of  the  mucous  mem- 
brane on  each  side  of  the  clamp.  After  the  removal  of  the  hemorrhoid  the 
edges  of  the  wound  fall  together.  We  are  accustomed  to  approximate  these 
edges  with  a  few  fine  catgut  stitches.  Some  regard  this  as  unnecessary.  The 
other  hemorrhoids  are  then  treated  in  the  same  way.  Nothing  but  an  external 
sterile  dressing  is  needed.  In  a  severe  case  the  bowels  are  kept  closed  for  nine 
days;  in  a  mild  case,  four  or  five  days. 

If  gas  is  troublesome,  a  very  fine  rubber  or  silver  tube  may  be  inserted  and 
left  for  several  hours  each  day.  The  bowels  may  be  moved  by  oil  catharsis  and 
enema. 

Whitehead's  Operation.— The  method  of  radical  removal  of  the  entire 
hemorrhoidal  area  should  not  be  used  as  a  routine  measure,  but  reserved  only 
for  those  severe  cases  where  the  hemorrhoids  appear  in  a  great  annular  pro- 
lapsed mass  about  the  anus  and  the  individual  piles  are  scarcely  distinguishable. 
Since  the  operation  was  announced  numerous  technics  have  been  described. 
We  are  accustomed  to  perform  the  operation  in  the  following  way: 


820 


GYNJEGOLOGY 


Patient  in  the  perineal  position.  The  sphincter  is  well  dilated.  Four 
points  are  taken  in  the  mucous  membrane  of  the  bowel  at  a  level  just  behind 
its  junction  with  the  anal  membrane.  At  these  points  sutures  with  long  ends 
are  placed,  to  be  used  for  the  purpose  of  traction  and  holding  the  bowel  in 


Fig.  479. — Operation  for  Hemorrhoids. 
Stretching  the  sphincter. 


position  for  further  manipulation..  The  incision  for  the  removal  of  the  annular 
mass  is  now  outlined  for  one-fourth  or  one-half'  the  circumference,  the  outer 
incision  being  at  the  junction  of  skin  and  anal  membrane,  and  the  inner  being 
at  the  junction  of  the  anal  membrane  and  that  of  the  bowel.  Care  must  be 
taken  not  to  carrv  the  incision  too  far  out  on  the  skin,  nor  too  far  in  on  the 


OPERATIONS    ON   THE    RECTUM 


821 


mucous  membrane,  in  either  of  which  cases  serious  contractions  may  later  de- 
velop. 

The  hemorrhoidal  mass  is  then  removed  by  knife  or  scissors  over  the  dis- 
tance marked  out.    Hemorrhage  is  stopped  by  deep  hgation  and  not  by  the 


\<P.G^ 


Fig.  480. — Ligation  of  Hemorrhoids. 
The  hemorrhoid  has  been  grasped  and  brought  to  view  by  fine  pressure  forceps.     The  hemorrhoid  is 

dissected  by  knife  or  scissors. 

sutures  that  approximate  the  skin  and  mucous  membrane.     When  the  hemor- 
rhage has  been  controlled  the  skin  and  mucous  membrane  are  united  with  fine 


Vl."^-G- 


Fig.  481. — Ligation  of  Hemorrhoids. 
The  hemorrhoid  has  been  dissected  out  and  its  pedicle  is  being  tied.     The  wound  may  be 
closed  with  a  fine  catgut  suture  or  it  may  be  left  without  suture,  the  edges  falling  together  naturally  in 
good  coaptation. 

catgut  sutures.    When  the  section  of  the  operation  first  outlined  has  been  com- 
pleted, another  section  is  treated  in  the  same  way.     It  often  happens  that  the 


822 


GYNECOLOGY 


skin  is  very  redundant  as  a  result  of  old  external  hemorrhoids.  In  this  case 
there  is  too  much  skin  to  match  the  corresponding  edge  of  mucous  membrane. 
This  difficulty  is  easily  obviated  by  cutting  wedge-shaped  pieces  from  the  re- 
dundant skin-flap  and  sewing  the  wedge  edges  with  fine  catgut.  With  a  httle 
ingenuity  the  skin-flap  can  be  made  to  fit  the  mucous  membrane  exactly. 

The  method  described  is  at  first  tedious,  but  after  a  few  trials  can  be  done 

rapidly. 

A  sterile  dressing  is  applied  to  the  anus.     The  bowels  are  kept  closed  for 
several  days.    If  swelhng  occurs,  it  is  reheved  by  appfications  of  hot  salt  solution. 


Fig.  482. — "Whitehead's  Operation  for  Hemorrhoids. 
Four  guide  sutures  have  been  placed  in  the  rectal  mucous  membrane  to  bring  it  down  into  view. 
The  circular  ring  of  hemorrhoids  is  being  dissected  off  with  knife  or  scissors,  care  being  taken  to  make 
the  wound  edges  smooth  and  even  and  not  to  carry  the  dissection  too  far  out  on  the  skin. 

Clamp  and  Cautery. — In  our  practice  the  clamp  and  cautery  method  of 
treating  hemorrhoids  has.  been  given  up  in  favor  of  dissection  and  hgature, 
because  of  the  greater  frequency  of  postoperative  fissure  and  of  the  higher  per- 
centage of  recurrence  in  the  former  method. 

The  operation  is  as  follows:  Dilatation  of  the  sphincter,  with  the  patient  in 
the  perineal  position.     The  most  conspicuous  hemorrhoid  is  seized  by  an  artery 


OPERATIONS    ON   THE    RECTUM 


823 


forceps  at  its  most  salient  point  and  lifted  up.  A  special  crushing-clamp  is 
then  applied  including  the  entire  pile,  but  not  implicating  the  skin  or  mucous 
membrane  of  the  bowel.  It  is  of  much  importance  that  the  clamp  be  adjusted 
to  the  pile  in  such  a  way  that  it  has  a  radial  direction  with  reference  to  the  cir- 
cumference of  the  anus.  This  is  to  insure  the  approximation  of  the  wound 
edges.      When  the  clamp  has  been  properly  adjusted  and  applied  so  as  to  crush 


Fig.  483. — Whitehead's  Operation  for  Hemorrhoids. 
The  ring  of  hemorrhoids  has  been  dissected  off.     The  mucous  membrane  of  the  rectum  is  being 
sewed  to  the  circular  wound  edge  of  the  skin.     It  is  convenient  to  place  four  sutures  first  as  in  the 
drawing.     If  the  skin  is  redundant  at  any  point  a  wedge-shaped  piece  may  be  cut  from  the  skin. 
In  this  way  the  wound  edge  of  the  skin  may  be  made  to  fit  exactly  that  of  the  mucous  membrane. 


the  artery  supplying  the  hemorrhoid,  the  portion  of  the  pile  projecting  above 
the  plane  of  the  clamp  is  burned  off  with  the  actual  cautery  kept  at  a  moderate 
dull-red  heat.  In  this  way  the  principal  hemorrhoids  are  removed.  There  is 
more  danger  from  postoperative  hemorrhage  after  this  operation  than  from  the 
other  two  methods  described.  The  after-treatment  should  be  the  same  and  as 
long  continued  after  this  operation  as  after  the  others. 


824 


GYNECOLOGY 


FISTULA  IN  ANO 

The  surgical  treatment  of  fistula  in  ano  consists  either  of  incision  of  the 
tract  and  open  treatment  of  the  wound,  or  of  dissection  of  the  fistulous  tract 
with  partial  closure  and  drainage  of  the  wound. 

By  the  first  method  a  director  is  passed  through  the  fistulous  opening  and 
out  through  the  anal  orifice  (Fig.  484).  The  tissues  are  then  slit  with  a  sharp 
knife  carried  along  the  groove  of  the  director.  In  this  way  a  part  of  the  sphincter 
muscle  is  always  cut.  This  may  do  no  harm  if  only  the  external  fibers  are  cut. 
If,  however,  the  internal  fibers  are  severed,  fecal  incontinence  is  likely  to  follow. 


Fig.  484. ^Fistula  in  Ano.     Open  Method  of  Operation. 
A  director  is  introduced  into  the  fistulous  tract  and  an  incision  made  along  the  director.     The 
open  wound  is  packed  and  allowed  to  granulate.     In  making  the  incision,  fibers  of  the  sphincter 
muscle  are  severed  to'  a  greater  or  less  extent. 


The  wound  is  packed  and  kept  open  with  iodoform  gauze  for  a  week  or  so, 
when  it  is  allowed  to  heal.  In  some  cases  the  open  method  just  described  is  the 
only  one  feasible,  especially  in  those  cases  where  the  surrounding  tissue  is  under- 
mined and  unhealthy. 

In  the  majority  of  cases  seen  in  gynecologic  chnics  the  dissection  method  is 
entirely  feasible  and  preferable.     The  author's  technic  is  as  follows: 

The  fistulous  tract  is  first  explored  with  a  fine  probe  to  determine  its  direc- 
tion, whether  it  is  simple  or  complex,  and  whether  or  not  it  communicates  with 


OPERATIONS    ON   THE    RECTUM 


825 


lumen  of  the  bowel.  A  director  is  then  introduced,  being  brought  out  through 
the  anal  orifice  if  there  is  a  definite  opening.  If  no  opening  is  found,  no  attempt 
is  made  to  force  it  through.  With  the  director  in  place,  an  incision  is  made  as 
shown  in  Fig.  485. 

It  is  on  the  principle  of  the  so-called  "apron"  incision  for  complete  tear  of 
the  sphincter  originally  devised  by  J.  C.  Warren,  and  is  designed  to  protect  the 
wound  as  much  as  possible  from  contamination  from  the  anal  orifice. 

A  semicircular  incision  is  made  through  the  skin-  outside  the  border  of  the 
anus.  At  right  angles  to  this  an  incision  is  made  to  the  fistulous  opening  along 
the  course  of  the  director.     On  reaching  the  fistulous  opening  the  incision 


Fig.  485. — Operation  i'or  Fistula  in  Ano  (Author's  Method). 
Dissection  of  the  tract.     A  director  is  introduced  into  the  fistulous  opening.     The  red  line  indicates 

the  line  of  incision. 


encircles  it  with  a  margin  of  about  I  inch.  Through  the  incision  thus  outlined 
the  fistula  is  now  dissected  out  as  a  tube  surrounding  the  director  (Fig.  486). 
In  order  to  keep  the  fistula  tense  for  the  purpose  of  dissection  it  is  seized  at  its 
end  with  a  pair  of  toothed  clamps,  by  which  it  can  be  held  in  a  convenient 
position;  the  dissection  is  then  carried  to  the  end  of  the  fistula.  If  there  are 
ramifications  of  the  fistulous  tract,  these  are  also  dissected  out.  As  little  damage 
is  done  to  the  fibers  of  the -sphincter  muscle  as  possible,  it  being  unnecessary 
sometimes  to  cut  them  at  all. 

If  the  fistula  has  entered  the  lumen  of  the  bowel  the  opening  is  first  closed 
with  fine  catgut  sutures  applied  from  the  wound  side.     If  the  sphincter  has  been 


826 


GYNECOLOGY 


injured,  fine  catgut  sutures  are  placed  in  such  a  manner  as  best  to  unite  the 
lacerated  fibers,  the  figure-of-8  stitch  being  especially  useful  in  accomplishing 
this  result.  When  the  dead  space  left  by  the  removal  of  the  fistula  has  been, 
for  the  most  part,  closed,  a  small  drain  of  folded  rubber  tissue  is  placed  in  the 
bed  of  the  wound  and  led  out  through  a  stab-wound  to  one  side  and  below  the 
level  of  the  operation.     The  wound  is  closed  with  deeply  placed  silkworm-gut 


Fig.  486. — Oper.a.tion  for  Fistula  in  Ano  (Author's  Method). 
The  fistulous  tract  has  been  dissected  down  to  its  entrance  into  the  rectal  canal.     During  the 
dissection  the  director  is  kept  in  to  serve  as  a  guide.     The  fistulous  tube  made  by  the  dissection  is 
kept  taut  by  a  pressure  forceps  attached  to  the  tissue  about  the  opening. 


sutures  which  are  shotted.  Any  inequalities  in  the  approximation  of  the 
wound  are  smoothed  over  with  superficial  stitches  of  fine  catgut,  a  matter  of 
considerable  importance  for  preventing  the  entrance  into  the  wound  of  con- 
taminating organisms. 

The  silkworm-gut  stitches  are  removed  on  the  ninth  day,  and  on  the  follow- 
ing day  the  patient's  bowels  are  moved  for  the  first  time  by  oil  catharsis  and 
enema.     The  small  drain  is  removed  on  the  third  day. 


OPERATIONS    ON   THE    RECTUM 


827 


The  results  of  this  operation  in  the  author's  hands  have  been  excellent,  the 
percentage  of  delayed  convalescence  and  discouraging  recurrence  being  much 
less  than  after  the  employment  of  other  methods.     One  of  the  chief  advantages 


Fig.  487.' — Operation  for  Fistula  in  Ano  (Author's  Method). 
The  fistulous  tract  has  been  dissected  out.     A  few  buried  approximating  stitches  of  fine  catgut 
have  been  applied  to  any  severed  fibers  of  the  sphincter  muscle.    The  wound  is  closed  by  silkworm- 
gut  sutures  the  ends  of  which  are  shotted.'     A  small  rubber  drain  is  placed  from  the  cavity  of  the 
wound  through  a  stab-wound  below  the  main  incision. 

of  the  operation  is  that  the  sphincter  muscle  receives  a  minimum  of  damage, 
and  if  it  is  seriously  injured  it  can  be  repaired  at  the  time  of  the  operation. 


ELTING'S  OPERATION  FOR  FISTULA  IN  ANO 

The  sphincters  are  first  thoroughly  dilated.  The  general  direction  of  the 
sinus  or  sinuses  is  first  investigated  with  a  fine  probe  through  the  external 
opening.  A  circumcision  is  then  made  about  the  anus  at  the  point  where  the 
mucosa  of  the  bowel  joins  the  skin,  as  in  the  Whitehead  operation  for  hemor- 
rhoids. The  mucous  membrane  of  the  bowel  is  dissected  upward  well  above  the 
internal  opening  of  the  fistula  if  it  can  be  demonstrated.  If  such  an  opening 
cannot  be  seen,  the  dissection  is  carried  to  the  ''white  line,"  which  indicates  the 


■828 


GYNECOLOGY 


insertion  into  the  rectum  of  the  levator  ani  muscle.  By  this  dissection  all  con- 
nection of  the  bowel  with  the  fistulous  tract  is  severed.  The  external  opening 
or  openings  are  then  dilated  and  the  fistulous  tract  in  all  its  ramifications  thor- 
oughly cureted,  care  being  taken  not  to  injure  the  sphincter  muscle.  The  free 
margin  of  bowel  made  by  the  first  dissection  is  now  trimmed  off  above  the  level 
of  the  internal  fistulous  opening,  and  the  edge  of  the  upper  segment  of  bowel 
united  to  the  skin  of  the  anus  by  interrupted  sutures  of  fine  silk  or  catgut,  as  in 
the  Whitehead  operation  for  hemorrhoids.  The  external  fistulous  opening  is 
hghtly  packed  with  gauze.  The  bowels  are  moved  in  two  days.  The  external 
openings  heal  gradually  by  granulation. 

VARICOSE  VEINS   OF  THE  LEG 

There  are  numerous  operations  employed  for  the  cure  of  varicose  veins,  all 
of  them  more  or  less  subject  to  failure.     Of  these  may  be  mentioned  the  circular 


W.P.G-rcvc>v>  s- 


Fig.  488. — Mayo's  Operation  for  Varicose  Veins. 
Showing  the  manner  of  making  the  incisions. 


incision  of  Schede;  multiple  incision  and  ligation;  Trendelenburg's  resection  of  a 
portion  of  the  internal  saphenous  vein  in  the  upper  thigh;  complete  dissection  of 
the  vein  by  long  incision,  and  Mayo's  subcutaneous  enucleation  with  a  specially 
devised  instrument. 

Of  these,  the  Trendelenburg  operation  is  the  simplest,  and  can  be  used  in 


OPERATIONS    ON   THE    RECTUM  '829 

many  cases,  especially  in  those  which  are  complicated  with  a  varicose  ulcer.  The 
Schede  operation,  once  popular,  is  at  present  comparatively  little  used.  Multiple 
incision  and  ligation  is  a  long  and  tedious  operation,  but  in  some  cases  must  be 
resorted  to.  Complete  dissection  of  the  vein  is  a  long  operation  and  entails 
too  great  a  risk  in  the  event  of  sepsis,  which,  in  view  of  the  extremely  long  wound, 
constitutes  a  grave  danger.  In  the  majority  of  cases  the  subcutaneous  enuclea- 
tion by  Mayo's  method  is,  in  our  experience,  the  most  desirable.  When  the  vein 
walls  are  very  thin  and  frangible  the  operation  does  not  work  out  as  smoothlj^ 
as  one  would  wish,  but  in  this  case  the  principle  of  enucleation  may  be  com- 
bined with  a  large  number  of  incisions,  and  satisfactory  results  obtained,  though 
the  operation  may  be  long  and  laborious.  The  technic  of  the  operation  is  as  fol- 
lows: The  leg  is  held  in  an  elevated  position  either  by  an  assistant,  who  holds 
the  patient's  heel  in  the  palm  of  the  hand,  or,  as  Mayo  recommends,  slinging 
the  foot  to  an  upright  at  the  end  of  the  operating  table.  A  small  transverse 
incision  is  made  on  the  inner  side  of  the  thigh  just  below  the  saphenous  opening. 
The  vein,  as  a  rule,  is  easily  found.  In  very  fat  patients,  in  whom  the  landmarks 
are  less  easy  to  determine,  it  may  be  necessary  to  enlarge  the  incision  one  way 
or  the  other  in  order  to  encounter  the  vein.  When  the  vein  has  been  found, 
it  is  severed,  the  proximal  end  being  ligated  and  the  distal  end  seized  with  a  clamp. 


J 


Fig.  4S9. — Instrument  Used  for  Stripping^  the  Vein  in  Mayo's  Operation  for  Varicose  Veins. 

The  distal  end  is  freed  and  drawn  out  a  short  distance  into  the  wound  and 
threaded  into  the  loop  at  the  end  of  the  enucleator.  This  is  a  special  instrument 
devised  for  this  operation  by  the  Mayos,  and  is  constructed  like  a  very  long 
blunt  curet,  with  the  end  bent  at  an  angle  (Fig.  489).  When  the  vein  has  been 
threaded  into  the  loop,  its  end  is  held  with  moderate  tension  by  a  clamp.  The 
enucleator  is  forced  gently  but  firmly  through  the  subcutaneous  tissues  toward 
the  knee  in  the  direction  of  the  vein.  An  assistant  steadies  the  tissues  with  his 
hands  placed  one  on  each  side  of  the  end  of  the  instrument.  As  the  enucleator 
is  forced  through  the  tissues  the  lateral  branches  of  the  vein  are  torn  off.  In  a 
favorable  case  the  point  of  the  instrument  may  be  carried  to  a  few  inches  above 
the  knee  before  it  becomes  impossible  to  push  it  further  without  exerting  too 
great  tension  on  the  vein.  The  point  is  then  forced  up  against  the  skin  and  a 
small  transverse  incision  made  over  it. 

The  vein  thus  brought  into  view  is  drawn  out  of  the  opening  and  also  from 
the  loop  of  the  instrument,  which  is  extracted  from  the  first  wound.  The  vein 
is  again  threaded  into  the  loop,  and  the  enucleator  forced  through  the  tissues 
to  a  point  below  the  knee.  This  section  of  the  vein  is  the  most  important  to 
remove,  and  also  the  most  difficult,  for  it  contains  branches  that  anastomose 
both  with  the  external  saphenous  vein  and  with  the  deep  venous  circulation  of 


830  GYNECOLOGY 

the  leg.  If  (as  in  our  experience  it  usually  does)  the  vein  breaks  during  the 
stripping  of  this  section,  an  incision  is  made  below  the  knee,  the  vein  isolated, 
and  the  enucleator  worked  upward  in  the  reverse  direction  toward  the  point  of 
rupture. 

Below  the  knee  the  vein  is  somewhat  more  adherent  than  above,  so  that 
the  incisions  must  be  made  more  frequently.  If  the  external  saphenous  is  vari- 
cose, the  same  procedure  is  carried  out  on  the  back  and  outer  part  of  the  leg. 

Bleeding  from  the  lacerated  branches  of  the  vein  is  rarely  troublesome  and 
can  easily  be  controlled  by  pressure. 

The  small  wounds  are  sewed  up  and  the  leg  kept  in  moderate  elevation 
during  convalescence.  It  is  best  for  the  patient  to  wear  an  elastic  stocking  for 
a  few  weeks  after  operation. 

If  a  varicose  ulcer  is  present  with  the  usual  brawny  induration  it  is  advisable 
to  treat  the  patient  first  for  a  period  in  a  hospital.  The  patient  is  kept  in  bed 
with  the  leg  elevated.  The  best  treatment  for  ulcer  is  Crede's  ointment  or  scarlet 
ointment.  The  effect  of  the  Crede  preparation,  which  is  made  from  silver  salts, 
is  sometimes  very  rapid. 

If  the  ulceration  is  not  cured  in  a  reasonable  time  the  operation  consists  of  a 
resection  of  the  vein  either  by  the  Trendelenburg  or  Mayo  operation,  preferably 
the  latter,  with  a  removal  of  the  section  extending  from  8  inches  above  the  knee 
to  4  inches  below  it.  The  ulcerated  area  is  then  dissected  out  and  the  surface 
thus  exposed  skin-grafted.  The  entire  leg  is  bandaged,  leaving  a  window  of 
celluloid  or  fine  gauze  elevated  from  the  wound  through  which  the  condition 
of  the  graft  may  be  daily  watched. 


TECHNIC 

Author's  Note. — In  writing  the  following  section  the  author  realizes  the  wide  divergence 
of  opinion  that  exists  among  gynecologists  in  regard  to  many  matters  of  technical  detail. 
The  methods  here  described  are  those  in  use  at  the  present  time  at  the  Brookline  Free  Hospital 
for  Women  and  are  the  result  of  many  years  of  trial  and  comparison  with  other  methods. 
To  the  experienced  gynecologist  who  has  worked  out  his  own  technic  the  section  may  be  of 
little  interest.  To  the  beginner  it  is  offered  either  for  imitation  or  as  a  groundwork  from 
which  an  individual  technic  may  be  developed.  Many  of  the  instructions  contained  in  this 
section  have  already  been  mentioned  throughout  the  book  in  discussing  the  treatment  of  the 
various  gynecologic  diseases. 

EXAMINATION   OF  THE   PATIENT 

Pelvic  examination  in  the  office  should  be  made  only  in  the  presence  of  an 
attending  nurse  or  a  female  friend  of  the  patient,  preferably  a  relative.  The 
patient  is  first  instructed  to  empty  her  bladder,  and  then  to-  loosen  her  clothing 
about  the  waist  and  to  remove  her  corsets.  The  nurse  arranges  the  patient 
on  the  table  with  a  sheet  draped  over  the  knees,  the  abdomen  being  exposed  so 
that  it  may  be  inspected  and  palpated.  It  is  inadvisable  to  cover  the  face, 
as  pain  and  tenderness  can  best  be  detected  by  watching  the  facial  expression. 

In  the  examination  of  a  gynecologic  patient  the  attention  should  first  be 
directed  to  the  abdomen.  Its  contour  will  give  evidence  of  large  tumors, 
abnormal  fat,  hernia  formation,  ascites,  accumulation  of  gas,  etc.  Undue 
laxity  of  the  abdominal  muscles  with  diastasis  is  frequently  noticeable  at  the 
first  glance. 

Palpation  of  the  abdomen  must  be  undertaken  with  the  utmost  gentleness 
and  delicacy  of  touch.  The  first  point  for  examination  should  alwaj^s  be  the 
uterine  region  immediately  above  the  pubes.  If  the  fundus  of  the  uterus  can 
be  felt  it  may  be  assumed  that  some  abnormality  is  present,  the  conditions 
which  produce  this  sign  being  most  commonly  pregnancy,  myoma,  or  a  tumor 
in  the  posterior  culdesac  which  presses  the  uterus  forward  into  anteposition. 
The  ovarian  regions  are  then  palpated,  at  first  gently,  then  firmly  and  deeply, 
for  the  discovery  of  possible  adnexal  tumors,  and  to  elicit  tenderness  if  pelvic 
inflammation  is  present. 

Attention  is  next  directed  to  the  abdominal  rectus  muscles,  with  special 
reference  to  undue  rigidity  or  laxness.  If  rigidity  and  tenderness  are  present, 
it  must  be  determined  whether  the  muscular  spasm  is  general,  or  whether  it  is 
confined  to  or  more  marked  in  one  muscle,  or  whether  it  is  localized  in  a  cer- 
tain area,  as  in  the  pelvis,  the  appendix  region,  the  epigastrium,  etc.  In  deter- 
mining muscular  spasm  of  the  abdominal  recti  it  is  of  the  very  greatest  im- 
portance to  distinguish  between  voluntary  and  involuntarj^  muscle  contrac- 
tions.    Many  patients  from  fear,  resentment,  or  lack  of  nervous  control  will 

831 


832  GYNECOLOGY 

hold  the  abdominal  muscles  in  a  continuous  state  of  rigid  contraction,  which 
makes  the  abdominal  examination  difficult  and  confusing. 

Relaxation  of  the  abdominal  wall  with  diastasis  is  usually  quite  apparent 
from  inspection  and  palpation.  It  is  made  more  evident  by  asking  the  patient 
to  cough,  or  still  better  by  raising  the  patient's  shoulders  a  few  inches  from  the 
table,  when  the  recti  are  brought  into  firm  contraction.  Umbilical  and  post- 
operative hernias  are  brought  into  prominent  view  in  this  way. 

Every  abdominal  examination  should  include  as  a  routine  careful  palpa- 
tion of  the  regions  of  the  appendix,  gall-bladder,  liver,  stomach,  kidneys,  and 
colon,  even  if  the  symptoms  do  not  call  particular  attention  to  these  organs. 

If  abdominal  enlargement  is  discovered,  one  must  first  determine  whether 
or  not  it  is  due  to  fat,  to  intestinal  distention,  or  to  ascites.  If  a  pelvic  tumor 
is  definitely  made  out  the  final  diagnosis  of  its  nature  must  usually  be  deferred 
until  the  vaginal  examination  is  made. 

When  all  possible  information  has  been  gained  from  palpation  of  the  abdo- 
men, the  vaginal  examination  is  undertaken. 

The  external  genitals  and  anus  are  first  inspected  under  a  good  light.  Ab- 
normal conditions  made  evident  by  inspection  are  genital  atrophy,  abnormal 
secretions,  urethral  caruncle,  enlargement  of  Skene's  and  Bartholin's  glands, 
skin  lesions  of  the  vulva,  procidentia,  relaxation  of  the  vaginal  outlet,  hemor- 
rhoids, etc.  If  the  outlet  is  relaxed  the  amount  of  prolapse  of  the  vaginal 
wall  is  best  determined  by  placing  the  forefingers  of  the  two  hands  in  the  two 
lateral  sulci  of  the  torn  perineum  and  pressing  firmly  downward  toward  the 
buttocks.  When  the  patient  is  requested  to  strain  as  in  the  act  of  defecation 
the  anterior  and  posterior  walls  of  the  vagina  roll  outward  and  show  distinctly 
the  amount  of  cystocele  and  rectocele  present. 

Digital  examination  by  vagina  is  first  made  with  the  left  forefinger,  which 
should  be  well  lubricated.  The  best  lubricants  are  made  from  glycerin  and 
sea-moss.  If  one  of  these  preparations  cannot  be  had,  soap  and  warm  water  is 
entirely  satisfactory.  Vaselin  preparations  are  disagreeable,  and  if  gloves  are 
used  are  injurious  to  the  rubber. 

The  left  forefinger  is  introduced  through  the  introitus  with  the  hand  in  the 
position  of  pronation,  pressure  being  exerted  on  the  perineum,  in  order  to  avoid 
as  much  as  possible  contact  with  the  urethra  and  chtoris.  Passage  through 
the  introitus  must  be  made  with  extreme  gentleness  and  deliberation,  for  any 
quick  or  rough  movement  will  cause  the  patient  to  contract  the  muscles  of  the 
abdomen  and  thighs.  .  When  the  first  phalanx  of  the  forefinger  has  passed  the 
introitus  the  hand  is  turned  into  the  position  of  supination,  which  gives  a  spiral 
motion  to  the  entering  finger.  The  patient  is  now  requested  to  relax  as  much 
as  possible,  and  this  is  best  accomphshed  by  separating  the  legs  widely.  If  the 
preliminary  part  of  the  examination  has  been  ungentle  or  inconsiderate  it  is 
impossible  to  secure  proper  relaxation  on  account  of  the  patient's  fear  of  being 
hurt. 


TECHNIC  833 

When  the  forefinger  has  reached  the  cervix,  the  external  os  is  palpated  and 
such  conditions  noted  as  the  direction  of  the  cervix,  laceration,  eversion,  hyper- 
trophy, cystic  nodules,  malignant  infiltration,  etc.  Next,  the  finger  feels  along 
the  anterior  wall  of  the  vagina,  noting  -the  anterior  wall  of  the  uterus,  if  it  is  in 
the  forward  position,  and  distinguishing  the  amount  of  angulation  between  cervix 
and  body.  The  lateral  and  posterior  fornices  of  the  vagina  are  explored  for  the 
discovery  of  such  abnormalities  as  vaginal  scars,  cysts,  hypoplastic  shortening, 
parametrial  infiltration,  or  the  protrusion  toward  the  vagina  from  above  of  a 
tumor  or  pelvic  abscess. 

The  right  hand  is  now  placed  on  the  abdomen  above  the  pUbes  and  a  bi- 
manual examination  made  of  the  internal  pelvic  organs.  The  position  of  the 
uterus  is  first  determined.  This  is  best  accomplished  by  placing  the  forefinger 
under  the  cervix  and  lifting  the  uterus  toward  the  abdominal  wall  until  the 
right  hand  can  palpate  the  fundus,  and  note  its  size,  consistency,  and  contour. 

If  by  hfting  the  uterus  toward  the  anterior  abdominal  wall  the  fundus  can- 
not be  felt  by  the  right  hand  the  uterus  must  be  in  some  form  of  retroposition, 
the  degree  of  which  is  then  determined  by  forcing  the  left  forefinger  deeply  into 
the  posterior  fornix  of  the  vagina  and  palpating  the  posterior  wall  of  the  uterus. 
If  the  vagina  is  deep  or  the  patient  very  fat,  this  last  maneuver  may  be  greatly 
facilitated  if  the  examiner  places  his  left  elbow  against  his  hip,  by  which  firm 
and  powerful  pressure  may  be  exerted  without  causing  the  patient  pain. 

Prolapse  of  the  uterus  is  measured  by  placing  the  left  forefinger  on  the  cervix 
and  requesting  the  patient  to  strain  as  in  the  act  of  defecation,  when  the  amount 
of  descensus  may  be  noted.  A  more  accurate  method  is  by  examination  in  the 
standing  position. 

When  the  position,  size,  and  consistency  of  the  uterus  have  been  investigated, 
the  sides  of  the  pelvis  are  explored.  The  examining  finger  passes  into  the  left 
posterior  fornix  of  the  vagina,  pressing  in  deeply,  while  the  right  hand  is  shifted 
to  the  lower  left  quadrant  of  the  patient's  abdomen  and  pressed  inward  as  if  to 
meet  the  forefinger  of  the  examining  hand.  In  this  way  the  adnexa  are  forced 
downward  toward  the  left  forefinger,  which  is  thus  enabled  to  palpate  the  lower 
hemisphere  of  the  ovary.  In  a  normal  pelvis  the  adnexa  cannot  be  felt  by  the 
external  hand,  while  the  finger  in  the  vagina  feels  only  one  pole  of  the  ovary 
unless  the  patient  is  very  thin.     A  normal  tube  cannot  ordinarily  be  palpated. 

Bimanual  examination  of  the  adnexa  reveals  such  pathologic  conditions  as 
prolapsed  and  cystic  ovaries,  ovarian  tumors,  tubal  pregnancy,  salpingitis, 
chronic  pelvic  inflammation  with  immobilizing  adhesions,  etc.  Of  great  im- 
portance in  examining  the  adnexa  is  the  detection  and  proper  interpretation 
of  pain,  and  here  again  must  be  emphasized  the  necessity  of  distinguishing  pain 
from  some  pathologic  process  and  that  which  may  be  elicited  by  rough  manipu- 
lation. 

When  the  adnexa  of  the  left  side  have  been  investigated  attention  is  directed 
to  the  right  side.    When  the  examiner  stands  between  the  patient's  knees  he  is 

53 


834  GYNECOLOGY 

liot  in  an  advantageous  position  to  explore  the  right  side  with  the  left  forefinger. 
The  left  forefinger  is,  therefore,  withdrawn  from  the  vagina  and  the  right  fore- 
finger inserted,  the  left  hand  now  being  used  on  the  abdomen. 

A  very  satisfactory  method  of  exploring  the  right  side  without  withdrawing 
the  left  forefinger  is  for  the  examiner  to  step  to  the  left  side  of  the  patient,  in 
which  position  it  is  easy  to  reach  deeply  into  the  right  fornix  of  the  vagina  with 
the  left  forefinger. 

When  it  is  necessary  to  inspect  the  cervix  and  upper  part  of  the  vagina  and 
to  make  local  applications,  a  speculum  must  be  used.  This  may  be  done  with 
the  patient  on  the  back,  in  which  case  a  bivalve  speculum  is  usually  employed. 

A  much  more  efficacious  and  convenient  method  is  the  classic  one  by  which 
the  patient  is  first  placed  in  the  Sims  position,  the  success  of  the  procedure 
depending  chiefly  on  securing  a  proper  position.  It  is  necessary  that  the 
examining  table  be  fitted  with  a  Sims  shelf  extending  from  the  left  lower 
corner.  The  patient  is  made  to  lie  on  her  left  side  with  feet  and  legs  supported 
by  the  shelf.  The  left  hip  should  correspond  as  closely  as  possible  to  the  lower 
right  corner  of  the  table.  The  right  shoulder  should  be  in  contact  with  the  right 
edge  of  the  table,  while  the  left  arm  rests  along  the  other  edge.  In  this  way  the 
patient  is  made  to  lie  upon  her  breast. 

The  nurse  stands  at  the  patient's  back,  separating  the  lips  of  the  vulva  with 
the  tips  of  the  fingers,  while  the  Sims  speculum  is  being  introduced  by  the  ex- 
aminer. When  the  speculum  has  been  properly  placed  the  nurse  seizes  it  firmly 
with  her  right  hand,  still  retracting  the  buttocks  with  the  fingers  of  her  left 
hand. 

In  order  to  secure  a  good  exposure  of  the  cervix  and  vault  of  the  vagina 
it  is  necessary  for  the  examiner  to  depress  the  anterior  vaginal  wall  with  a  cotton 
stick  or  other  convenient  instrument.  The  Sims  position  is  of  especial  advantage 
in  inspecting  the  cervix,  for  removing  specimens  of  tissue  for  microscopic  ex- 
aminations, for  probing  the  cervical  canal,  and  for  the  apphcation  of  tampons 
and  medicinal  substances  to  the  vaginal  canal. 

Occasionally  the  knee-chest  position  is  useful  for  vaginal  examinations.  In 
this  position  two  Sims'  speculums  may  be  employed,  applied  one  to  the  poste- 
rior and  one  to  the  anterior  wall  of  the  vagina.  The  knee-chest  position  is  un- 
comfortable and  disagreeable  to  the  patient,  and  as  it  has  httle  advantage  over 
the  Sims  position  it  need  rarely  be  used. 

PELVIC   EXAMINATION   IN   A   PRIVATE   HOUSE 

Whenever  possible  gynecologic  patients  should  be  examined  at  the  office, 
on  a  proper  table  with  good  hght.  When,  however,  it  is  necessary  to  make  the 
examination  at  the  patient's  home  the  patient  is  instructed  to  be  in  bed.  The 
abdominal  part  of  the  examination  is  made  with  the'  patient  lying  near  the  edge 
of  the  bed.    For  the  bimanual  part  of  the ,  examination  it  is  advantageous  for 


:  TECHNIC  833 

the  patient  to  lie  across  the  bed.  In  order  to  bring  the  pehds  into  a  good  position 
for  palpation  of  the  organs  the  buttocks  should  extend  over  the  edge  of  the  bed, 
the  feet  being  supported  on  two  chairs  or  on  the  knees  of  the  examiner,  who  is 
seated  in  a  chair  in  front  of  the  patient.  If  in  this  position  the  examination  is 
unsatisfactory,  it  may  be  facilitated  by  having  an  assistant  sit  on  the  bed  beside 
the  patient  and  raise  the  thighs  until  they  are  in  contact  with  the  abdomen. 

ABDOMINAL   OPERATIONS 

Preparation. — In  the  performance  of  pelvic  operations  by  the  abdominal 
route  the  preparation  of  the  bowels  is  of  very  great  importance,  for  if  they  are 
distended  and  cannot  easily  be  kept  away  from  the  surgical  field  the  technical 
difficulties  of  the  operation  are  greatly  increased.  Moreover,  a  thorough  prepara- 
tion of  the  bowels  insures  to  a  certain  extent  against  troublesome  postoperative 
gas  formation.  Surgeons  differ  considerably  in  the  matter  of  catharsis,  castor 
oil  and  calomel  being  the  drugs  most  commonly  used.    Our  method  is  as  follows: 

Unless  the  case  is  one  of  emergency  the  patient  is  required  to  enter  the 
hospital  on  the  second  afternoon  before  the  day  set  for  the  operation.  This 
is  done  chiefly  in  order  that  the  patient  may  pass  through  the  somewhat  deplet- 
ing experience  of  catharsis  at  least  twenty-four  hours  before  the  operation  and 
have  a  night  of  unbroken  rest  umiiediately  prececUng  her  ordeal.  Accordingly, 
on  the  afternoon  of  entrance  into  the  hospital  calomel  in  ^-grain  doses  is  given 
every  half-hour  until  4  grains  have  been  administered.  Calomel  given  in  doses 
of  this  size  passes  rapidly  through  the  intestinal  tract,  and  only  very  rarely 
causes  any  of  the  disagreeable  digestive  and  constitutional  symptoms  com- 
monly ascribed  to  its  use.  If  only  a  short  time  is  available  for  the  preparation 
of  the  bowels  it  is  better  to  use  castor  oil. 

Early  the  following  morning  the  patient  receives  |  ounce  of  Epsom  salts  and 
in  about  one  hour  is  given  a  high  enema  of  soapsuds  (1  pint).  By  this  form 
of  catharsis  the  patient  undergoes  a  thorough  cleansing  of  the  bowel,  but  is  not 
drastically  purged. 

After  the  enema  the  patient  receives  the  preliminary  skin  preparation,  which 
is  carried  out  in  the  following  way :  Hospital  patients  are  first  given  a  warm  tub 
bath.  The  abdomen  and  vulva  are  shaved  and  scrubbed  with  soap  and  water  and 
alcohol.  A  vaginal  douche  of  sterile  water  is  given.  Dry  sterile  pads  are  then 
applied.  The  patient  is  allowed  to  be  up  and  about  the  rest  of  the  day.  Private 
patients  are  permitted  to  leave  the  hospital  during  the  day  and  return  at  5 
o'clock.  At  that  time  the  abdomen  is  washed  with  70  per  cent,  alcohol,  and 
then  painted  with  tincture  of  iodin  diluted  with  70  per  cent,  alcohol  (1  to  3). 
A  fresh  sterile  pad  is  applied. 

Early  on  the  morning  of  the  operation  a  cleansing  suds  enema  and  another 
vaginal  douche  of  sterile  water  are  given.  When  the  patient  has  been  anes- 
thetized the  abdomen  is  again  painted  with  tincture  of  iodin  (1  to  3). 


836  GYNECOLOGY 

The  above  preparation  of  the  vulva  and  vagina  is  carried  out  as  a  routine 
measure  in  conjunction  with  the  preparation  for  all  gynecologic  abdominal 
operations  to  provide  for  possible  vaginal  examination  or  drainage  that  may 
unexpectedly  be  required  during  the  course  of  the  operation. 

If  the  abdominal  operation  is  preceded  by  a  vaginal  operation  the  vulva 
and  vagina  receive  an  extra  cleansing  after  the  patient  is  anesthetized  and  im- 
mediately preceding  the  operation  in  the  manner  described  below  for  the  prepara- 
tion of  vaginal  operations. 

Technical  Detail  in  the  Conduct  of  Abdominal  Pelvic  Operations 

The  patient  should  empty  her  bladder  just  before  taking  the  anesthetic. 
It  is  advisable  to  anesthetize  the  patient  on  the  operating  table  in  a  room  ad- 
joining the  operating  room.  When  the  patient  is  fully  anesthetized  whatever 
vaginal  preparation  is  necessary  should  be  carried  out  before  wheeling  the 
patient  into  the  operating  room.  If  the  operation  is  to  be  for  a  pelvic  tumor  it  is 
best  to  catheterize  the  bladder  in  order  to  determine  the  position  of  the  bladder, 
and  to  draw  off  any  possible  residual  urine,  the  presence  of  which  might  inter- 
fere with  the  performance  of  the  operation. 

The  patient  is  then  placed  in  the  Trendelenburg  position  and  the  table 
wheeled  into  the  operating  room,  where  a  coat  of  iodin  is  applied  to  the  ab- 
domen and  the  patient  properly  draped  with  sterile  coverings. 

If  the  incision  is  to  be  a  median  one  care  should  be  exercised  to  make  it  ex- 
actly in  the  middle  line,  and  not  longer  than  is  necessary  for  the  proper  per- 
formance of  the  intended  operation.  All  small  vessels  in  the  abdominal  fat 
should  be  caught  at  once  with  curved  half-length  clamps  which  fall  out  of  the 
way  when  in  place.  If  the  aponeurosis  is  exposed  without  staining  it  with  blood 
the  linea  alba  is  usually  visible  at  once.  The  fascia  is  opened  along  this  line, 
the  scalpel  entering  the  fatty  space  between  the  bellies  of  the  rectus  muscles. 
The  muscles  are  separated  with  a  few  touches  of  the  knife  and  the  subperitoneal 
fat  brought  to  view.  The  surgeon  then  places  the  forefingers  of  both  hands 
in  the  wound  and  strips  back  the  fat  from  the  peritoneum,  at  the  same  time 
releasing  the  peritoneum  from  the  under  sheath  of  the  rectus  muscles  for 
a  short  distance  from  the  wound.  The  peritoneal  layer  thus  thinned  out  is 
picked  up  with  thumb  forceps  by  the  surgeon  and  the  assistant  and  the 
peritoneum  opened  between  the  forceps  by  one  delicate  stroke  of  the  knife. 
The  opening  thus  made  is  enlarged  by  scissors  until  it  will  admit  the  hand 
of  the  operator,  unless  for  some  reason  it  is  important  that  the  wound  be  very 
small. 

The  first  step  is  always  to  investigate  the  pelvis.  If  the  pelvic  condition,  is  a 
serious  one,  such,  as  a  tumor  or  pelvic  inflammation,  attention  is  at  once  directed 
to  that  without  further  exploration  of  the  abdominal  cavity,  this  procedure 
being  deferred  until  the  end  of  the  operation,  and  then  carried  out  only  if  the 


TECHNIC  837 

patient's  condition  warrants  it  or  if  sepsis  has  not  been  encountered  during  the 
pelvic  operation. 

If  the  pelvic  condition  is  simple,  requiring  only  a  few  minutes  for  its  cor- 
rection, as  in  the  case  of  an  uncomplicated  retroversion,  the  appendix  is  sought 
for  and  removed.  The  left  hand  is  then  introduced  into  the  abdominal  cavity 
and  all  parts  rapidly  explored,  especial  attention  being  paid  to  the  palpation  of 
the  gall-bladder  and  to  abnormal  adhesions  in  any  part  of  the  intestinal  tract. 

If  the  pelvic  condition  demands  a  serious  operation  the  abdominal  wound 
is  enlarged  according  to  the  requirements  of  the  case,  a  hysterectomy  demand- 
ing an  incision  of  the  fascia  well  down  to  the  symphysis.  When  the  incision 
has  been  properly  enlarged  retractors  are  placed  in  the  wound  and  the  intestines 
packed  away  from  the  field  of  operation.  This  may  be  accomplished  in  the 
following  way:  The  anesthetist  has  been  previously  instructed  to  have  the 
patient  deeply  narcotized  at  this  point  of  the  operation,  for  if  this  is  not  done  the 
manipulation  of  the  intestines  and  the  irritation  of  the  gauze  packing  coming 
in  contact  with  the  peritoneum  will  stimulate  contractions  of  the  abdominal 
muscles  with  consequent  delay  of  the  operation.  In  order  to  remove  the  in- 
testines from  the  operative  field  the  surgeon  first  lifts  with  his  left  hand  the 
coils  of  bowel  which  He  in  the  pelvis  and  pushes  them  toward  the  upper  ab- 
domen. With  his  right  hand  he  pulls  down  the  omentum  so  as  to  cover  the 
intestines  as  much  as  possible.  A  "Western  strip"  wrung  out  in  warm  salt 
solution  is  then  placed  against  the  omentum  and  folded  back  and  forth,  forcing 
the  intestinal  contents  into  the  upper  abdominal  cavity.  A  second  strip  is 
applied  in  like  manner  to  tuck  back  any  loops  of  intestine  that  may  tend  to 
escape.  A  dry  gauze  handkerchief  is  applied  in  front  of  the  two  strips.  In 
this  way  the  bowel  is  completely  walled  off  from  the  field  of  operation  in  the 
pelvis.  By  first  bringing  down  the  omentum  and  then  using  moist  gauze  a 
minimum  of  trauma  is  done  to  the  peritoneal  surface  of  the  intestines.  If 
the  bowel  is  involved  in  extensive  pelvic  adhesions  these  must  be  released  before 
the  walling-off  gauze  is  apphed.  A  strict  count  of  the  sponges  used  during  the 
operation  must  be  made  by  two  persons  and  a  written  record  kept  by  the  operat- 
ing room  nurse. 

Various  devices  are  employed  to  prevent  the  possible  leaving  in  of  a  sponge  in 
the  abdominal  cavity.     One  of  these  consists  of  strips  of  braid  sewed  to  the  gauze 
sponges  with  leaden  weights  attached.     Wakefield  uses  a  very  long  strip  of 
gauze  which  is  fed  from  a  pocket  in  the  sterile  abdominal  sheet,  in  which  it  is  . 
folded  and  fastened. 

Some  operators  protect  the  edges  of  the  wound  with  napkins  fastened  to  the 
skin  with  small  towel  clips.     We  have  not  found  this  necessary. 

In  the  performance  of  pelvic  operations  it  is  important  that  the  surgeon 
adopt  a  definite  line  of  procedure  for  each  operation,  and  follow  the  same 
technic  step  by  step  each  time  he  does  the  operation.  In  this  way  he  is  enabled 
not  only  greatly  to  increase  the  speed  with  which  he  works,  but  to  receive  much 


838  GYNECOLOGY 

more  efficient  help  from  his  assistants,  who  in  a  short  time  learn  to  anticipate  his 
every  want. 

Success  in  pelvic  surgery  depends  largely  on  the  avoidance  of  loss  of  blood. 
Bleeding  confuses  the  operation,  causes  delay,  and  is  almost  exclusively  the  cause 
of  postoperative  shock.  It  can  best  be  prevented  by  rehgiously  following  the 
rule  always  to  clamp  or  hgate  a  vessel  before  cutting  it.  The  important  vessels 
of  the  pelvis  should  be  tied  twice  and  a  generous  stump  left  beyond  the  tie  to 
avoid  later  retraction. 

The  suture  material  used  in  pelvic  surgery  in  our  practice  is,  for  the  most 
part,  chromicized  catgut  of  various  sizes.  The  ovarian  and  uterine  vessels 
should  be  tied  with  No.  2  chromic  gut.  The  ties  are  made  twice  with  triple 
knots.  Other  vessels  may  be  tied  with  No.  1  or  No.  0,  depending  on  their  size 
and  location.  Small  vessels  in  the  bladder  and  intestinal  walls  are  tied  with 
No.  00  gut.     Peritoneal  surfaces  are  stitched  with  No.  0  or  No.  00. 

In  the  pelvis  it  should  be  kept  in  mind  that  knots  and  sutures  are  a  prolific 
cause  of  postoperative  adhesions.  The  surgeon  must,  therefore,  continually 
exercise  his  ingenuity  in  avoiding  as  much  as  possible  the  exposure  of  the  suture 
material  to  peritoneal  surfaces. 

The  difficulties  of  pelvic  surgery  depend  to  a  great  extent  on  the  inaccessi- 
bility of  the  field  of  operation.  Thus,  operations  which  under  favorable  condi- 
tions are  comparatively  simple,  may  present  the  most  serious  technical  diffi- 
culties if  the  abdominal  wah  is  very  fat,  or  if  the  incision  is  too  small,  or  if  the 
abdominal  muscles  are  in  contraction  from  incomplete  narcosis,  or  if  the  intes- 
tines are  distended  with  gas. 

One  way  in  which  operators  often  make  trouble  for  themselves  is  by  the 
collection  of  a  great  number  of  clamps,  which  obstruct  the  surgeon's  view,  pre- 
vent easy  manipulation,  and  cause  repeated  tangles  in  the  attempts  to  place 
hgatures.  In  a  difficult  pelvic  operation,  like  that  for  cancer  of  the  cervix,  for 
example,  it  saves  time  to  tie  the  vessels  as  they  are  caught  and  to  keep  the  field 
free  from  clamps. 

In  releasing  pelvic  adhesions  the  surgeon  must  exercise  precision  and  de- 
hberation,  most  of  the  accidents  that  happen  during  this  process  being  the  result 
of  haste  or  impatience.  On  the  other  hand,  he  must  be  sure  that  steady  progress 
is  being  made,  for  time  passes  very  rapidly  when  one  is  timidly  puttering  over 
some  difficult  adhesion. 

When  the  pelvic  operation  has  been  finished  the  condition  of  the  patient 
is  noted,  and  if  it  is  satisfactory  and  the  operation  has  not  already  consumed 
too  much  time,  the  appendix  is  sought  for  and  removed. 

If  no  pus  or  other  infecting  condition  has  been  encountered  during  the 
pelvic  operation  the  walhng-off  gauze  is  extracted  and  the  abdominal  cavity 
explored,  special  search  being  made  for  possible  gall-stones.  The  great  omen- 
tum, if  it  is  sufficiently  ample,  is  now  drawn  down  over  the  field  of  operation  and 
the  wound  closed. 


TECHNIC  839 

If  pus  has  been  encountered  the  patient  is  lowered  into  the  horizontal  posi- 
tion and  the  dry  handkerchief  gauze  removed.  The  surgeon  then  changes  his 
gloves  and  extracts  the  remaining  strips.  The  intestines  are  not  handled  at  all 
and  no  attempt  is  made  to  explore  the  abdominal  cavity. 

Suture  of  Abdominal  Wound. — In  sewing  up  the  abdominal  wound  there 
are  many  methods,  that  employed  by  the  author  being  as  follows: 

The  ends  of  the  wound  in  the  peritoneum  are  seized  with  half-length  clamps 
which  draw  the  peritoneal  folds  well  up  from  the  rest  of  the  wound.  The  edges 
of  the  peritoneum  are  sewed  by  a  running  suture  of  No.  1  chromic  gut,  beginning 
at  the  upper  end.  When  the  stitch  has  reached  the  lower  end  and  is  about  to  be 
tied  tension  on  the  peritoneum  is  released,  and  as  much  air  as  possible  is  allowed 
to  escape  from  the  abdominal  cavity  through  the  small  opening  in  the  perito- 
neum. Three  or  four  sutures  of  No.  1  chromic  gut  are  then  introduced  into  the 
bellies  of  the  recti  muscles  and  tied  sufficiently  tight  to  approximate  the  muscles, 
but  not  tight  enough  to  cause  a  paralysis  or  necrosis  of  the  muscle-fibers.  If  the 
muscles  are  so  separated  that  they  cannot  be  approximated  without  due  tension 
the  skin  wound  is  extended,  and  the  operation  for  diastasis  described  on  page  771 
is  performed. 

When  the  sutures  in  the  muscle  bellies  have  been  tied  the  corners  of  the  fascia 
are  caught  by  toothed  half-length  clamps.  If  the  wound  is  a  short  one,  without 
lateral  tension,  the  fascia  is  closed  by  a  single  running  suture  of  No.  1  chromic  gut. 
If  the  wound  is  a  long  one  or  if  there  is  considerable  lateral  tension,  such  as  exists 
in  fat  abdominal  walls,  the  upper  half  of  the  wound  is  closed  with  a  No.  2  chromic 
gut  suture  which  is  tied  at  the  center  of  the  wound.  A  second  suture  of  the  same 
size  is  then  introduced  at  the  lower  corner  and  the  lower  half  of  the  wound  is 
closed  in  like  manner.  All  the  small  vessels  of  the  fat  previously  caught  in  clamps 
are  tied  with  No.  00  chromic  gut. 

The  patient  is  now  let  down  into  the  horizontal  position.  By  this  change 
it  frequently  happens  that  other  small  vessels  in  the  fat  or  just  under  the  skin 
begin  to  bleed.  These  are  observed  carefully,  clamped,  and  tied.  This  maneuver 
is  a  rather  important  precaution  against  the  postoperative  bleeding  and  conse- 
quent hematoma  of  the  wound.  The  skin  and  fat  are  approximated  by  several 
deeply  placed  sutures  of  silkworm  gut.  In  order  to  secure  exact  coaptation  of 
the  skin  edges  a  running  stitch  is  used  of  No.  00  chromic  gut  and  introduced 
with  a  very  long  Glover's  needle  held  in  the  hand.  The  method  of  using 
a  subcutaneous  stitch  for  the  skin  coaptation  we  have  discarded.  A  sterile 
dressing  is  then  applied  to  the  wound  and  fastened  with  a  few  adhesive 
straps.  If  the  wound  is  very  extensive,  like  that  from  a  hernia  operation, 
broad  adhesive  straps  are  applied  overlapping  each  other  and  covering  the 
lower  part  of  the  abdomen.  Outside  of  this  dressing  is  placed  a  many-tailed 
binder. 

The  deep  silkworm-gut  sutures  are  removed  on  the  fifth  or  sixth  day.  The 
coaptation  stitch  of  fine  catgut  absorbs  for  the  most  part  during  the  final  days  of 


840  GYNECOLOGY 

convalescence,  but  it  is  usually  necessary  to  pick  from  the  wound  a  few  remaining 
bits  of  the  suture  before  the  patient  leaves  the  hospital. 

Postoperative  Treatment  of  Abdominal  Cases 

In  our  hospital  practice  no  morphin  or  other  narcotic  is  given  either  before 
or  after  operation  in  the  routine  case.  This  rule  we  have  not  been  able  to  carry 
out  consistently  in  our  private  practice,  in  which  many  of  the  patients  receive 
one  or  more  doses  of  morphin  during  the  first  thirty-six  hours  following  opera- 
tion. It  is  a  very  significant  fact,  however,  that  the  hospital  patients  are,  on  an 
average,  at  least  a  day  ahead  of  the  private  patients  during  the  first  part  of 
convalescence.  This  difference  in  favor  of  the  hospital  cases  is,  in  considerable 
measure,  undoubtedly  due  to  the  fact  that  drug  narcosis  is  not  employed.  The 
personal  element  must  in  all  surgical  work  be  kept  constantly  in  mind,  and  it 
cannot  be  denied  that  women  in  comfortable  circumstances,  whose  training  in 
life  has  been  less  rigorous  than  that  of  the  less  fortunate  classes,  are  physically 
more  sensitive  to  the  first  postoperative  discomforts  and  more  frequently  require 
the  relief  afforded  by  drugs,  which  are  given,  as  a  rule,  rather  to  prevent  nervous 
exhaustion  than  as  an  alleviation  of  actual  pain.  When  in  the  average  case 
morphin  is  indicated  it  is  our  practice  to  administer  |  grain  subcutaneously 
several  hours  after  the  operation  if  the  patient  is  beginning  to  get  restless. 
During  the  first  night,  if  it  seems  evident  that  the  patient  is  becoming  tired  out 
either  from  pain  or  nervous  from  loss  of  sleep,  another  I  grain  of  morphin  is 
allowed,  combined  with  y^-o-  of  hyoscin.  Usually  no  further  narcosis  is  necessary, 
except  with  very  nervous  or  excitable  patients. 

The  question  of  moving  the  bowels  after  an  abdominal  operation  is  an 
important  and  sometimes  troublesome  one.  In  the  treatment  of  routine  cases 
three  methods  may  be  employed,  each  one  of  which  has  its  adherents.  Either 
catharsis  may  be  begun  as  soon  as  possible  after  the  operation,  or  it  may  be 
started  two  or  three  days  after,  or  the  bowels  may  be  left  entirely  alone  until 
they  move  spontaneously. 

In  our  experience  the  first  method  brings  the  best  results  as  regards  rapid 
and  comfortable  convalescence,  and  we  have  employed  it  almost  universally  in 
our  hospital  practice  and  in  the  majority  of  our  private  cases.  In  detail  the 
method  is  as  follows :  About  fifteen  to  eighteen  hours  after  operation  the  pa- 
tient is  given  3  grains  of  calomel  in  ^-grain  doses  at  half-hour  intervals.  One 
hour  after  the  last  dose  |  ounce  of  magnesium  sulphate  is  administered.  Four 
hours  later  a  high  soapsuds  enema  (1  pint)  is  given.  In  the  great  majority  of 
cases  the  enema  is  followed  by  expulsion  of  gas  and  a  colored  watery  movement 
of  the  bowels  containing  flakes  of  feces.  If  the  enema  is  unsuccessful,  it  may 
be  repeated  in  two  or  three  hours  with  1  dram  of  turpentine  added  to  the  soap- 
suds. .  With  this  treatment  it  is  only  rarely  that  the  patient  does  not  have  a 
fairly  comfortable  second  day.     On  the  second  night  a  cathartic  is  given,  prefer- 


TECHNIC  841 

ably  in  the  form  of  a  compound  rhubarb  pill  (gr.  v).  On  the  following  morning 
the  patient  receives  another  suds  enema.  This  sequence  is  repeated  during  the 
rest  of  the  convalescence — i.  e.,  cathartic  pill  at  night  and  an  enema  the  follow- 
ing morning — even  if  the  bowels  move  spontaneously. 

This  method  of  early  postoperative  catharsis  is  less  successful  if  it  has  been 
necessary  to  give  morphin.  When  properly  carried  out  the  convalescence  is 
remarkably  rapid  and  only  very  exceptionally  attended  with  the  prolonged  dis- 
comforts of  gas,  nausea,  etc.  By  its  use  also  the  problem  of  nourishment  is 
greatly  simplified.  During  the  first  day  after  the  operation  sips  of  hot  water 
are  given  at  frequent  intervals  until  4  ounces  can  be  retained.  Dram  doses 
of  cold  milk  and  hme-water  in  equal  parts  are  then  given.  On  the  second  day 
the  patient  has  a  cereal  for  breakfast,  egg  and  toast  at  noon,  and  milk-toast  at 
night.  On  the  third  day  the  diet  is  the  same  as  on  the  second,  while  on  the 
fourth  day  the  patient  is  given  the  regular  house  diet. 

The  second  method,  that  of  delaying  the  catharsis  until  the  second  or  third 
night,  must  in  some  cases  be  resorted  to,  but  its  results  are  far  less  satisfactory 
than  those  of  the  first  method.  If  there  is  severe  reaction  from  the  operation, 
or  if  there  is  prolonged  nausea  from  the  anesthetic,  or  if  the  patient's  stomach  is 
extremely  dehcate,  it  is  best  not  to  attempt  early  catharsis.  As  a  rule,  patients 
of  this  kind  begin  to  be  troubled  with  gas  on  the  second  day.  If  it  is  accom- 
panied by  distention,  various  enemas  must  be  tried  to  relieve  the  patient's  dis- 
tress. The  formation  of  gas  is  likely  to  continue  until  satisfactory  catharsis 
has  been  estabhshed,  and  it  is,  therefore,  advisable  to  institute  it  as  soon  as  the 
patient's  stomach  has  become  settled.  The  choice  of  a  cathartic  is  then  a  diffi- 
cult one,  for  under  these  circumstances  the  stomach  is  in  very  unstable  equihb- 

rium. 

In  our  experience  calomel  is  useful  only  when  used  soon  after  the  operation, 
and  is,  therefore,  not  available  in  these  cases.  Castor  oil  is  most  efficacious, 
but  is  not  always  tolerated  by  the  patient.  Other  cathartics,  such  as  rhubarb, 
cascara,  phenolphthalein,  German  powder,  may  be  chosen.  Pluto  water  in 
2-  and  3-ounce  doses  on  the  morning  of  the  third  day  usually  works  well.  It 
should  be  followed  by  an  enema  in  a  few  hours  if  the  bowels  do  not  move  spon- 
taneously.    Fabery's  salts  used  in  the  same  way  we  have  found  excellent. 

The  third  method  of  treating  the  bowels  in  postoperative  abdominal  cases 
is  to  leave  them  alone  until  they  move  of  themselves.  We  have  not  found  this 
a  particularly  useful  method  for  treating  routine  cases,  for  although  it  frequently 
works  out  successfully,  in  many  instances  gas  formation  takes  place,  and  the 
patient  falls  into  the  second  class  described  above,  where  catharsis  and  enemata 
become  imperative.  We  are  accustomed  to  adopt  the  method  only  in  those 
cases  in  which  active  peristalsis  might  be  dangerous,  as  after  resection  of  the 
bowels,  or  when  there  is  possibility  of  a  general  peritonitis.  We  also  employ  the 
method  when  the  operation  has  been  attended  with  profound  shock.  In  these 
cases  salt  solution  in  small  quantities  (4  ounces)  is  introduced  into  the  rectum 


842  GYNECOLOGY 

at  frequent  intervals  until  the  patient's  condition  becomes  satisfactory.  Such 
patients  usually  have  a  spontaneous  movement  of  the  bowels  in  a  few  days. 

Length  of  Stay  in  Bed  of  Abdominal  Cases. — Patients  who  have  undergone 
such  routine  gynecologic  abdominal  operations  as  uterine  suspension,  myo- 
mectomy, supravaginal  hysterectomy,  oophorectomy,  appendectomy,  etc=,  and 
whose  convalescence  has  been  normal,  remain  in  bed  from  seven  to  nine  days, 
and  can  leave  the  hospital  in  from  twelve  to  sixteen  days. 

Patients  on  whom  operations  for  hernia  or  diastasis  of  the  abdominal 
muscles  have  been  performed  should  remain  in  bed  from  two  to  three  weeks, 
according  to  the  magnitude  of  the  operation  and  the  condition  of  the  abdominal 
wall.  Fat  patients  usually  remain  longer  than  thin  because  of  the  greater  danger 
of  postoperative  hernia. 

The  provision  for  adequate  abdominal  support  following  all  abdominal  cases 
is  of  great  importance,  and  should  in  no  instance  be  neglected.  For  the  average 
woman  a  well-fitting  modern  corset,  reaching  below  the  abdominal  wound  and 
exerting  firm  pressure  over  the  lower  abdominal  region,  is  the  best  form  of  sup- 
port. Very  fat  women  require  specially  made  corsets  or  abdominal  belts.  The 
best  form  of  belt  is  made  of  webbing.  The  belt  should  be  so  constructed  as  to 
support  and  elevate  the  lower  pendulous  part  of  the  abdomen.  It  should  be 
worn  continuously  except  at  night. 

TECHNIC   OF  PLASTIC   SURGERY 

Preparation. — Twenty-four  hours  before  the  proposed  operation  the  patient 
is  given  |  ounce  of  Epsom  salts.  The  vulva  is  shaved  and  scrubbed  with  soap 
and  water.  The  vagina  is  thoroughly  cleansed  with  green  soap  and  sterile 
water.     The  vulva  is  dried  and  a  dry  sterile  pad  applied. 

Four  or  five  hours  later  the  patient  is  given  a  high  soapsuds  enema.  The 
sterile  water  vaginal  douche  is  repeated,  the  vulva  cleansed,  and  the  dry  sterile 
pad  reapphed.  If  the  patient  is  obhged  to  urinate  or  have  a  movement  of  the 
bowels,  the  external  parts  are  irrigated  and  a  fresh  pad  apphed. 

Early  on  the  morning  of  the  operation  enemas  are  given  until  the  water 
returns  from  the  bowel  clear.  This  is  an  important  part  of  the  preparation,  for 
only  by  this  means  can  the  bowels  be  surely  prevented  from  moving  on  the 
operating  table  and  soihng  the  field  of  operation.  Again  the  vagina  is  douched 
and  a  sterile  pad  reapplied. 

When  the-  operation  is  to  be  for  complete  tear  of  the  perineum  the  prepara- 
tion is  the  same  except  that  castor  oil  is  given  as  a  cathartic  instead  of  salts, 
the  idea  being  that  the  movements  from  the  oil  are  less  irritating.  The  diet  of 
these  cases  should  be  restricted  on  the  day  preceding  the  operation,  especially 
as  regards  milk. 


TECHNIC 


843 


Technical  Details  in  the  Performance  of  Plastic  Operations 

When  the  patient  is  fully  anesthetized  the  lower  leaf  of  the  operating  table 
is  dropped  and  the  patient  placed  with  the  buttocks  just  projecting  over  the  edge 
of  the  table.  The  legs  are  drawn  up  with  knees  bent  until  the  thighs  rest  on  the 
patient's  body.     The  legs  are  held  in  this  position  by  a  nurse  assistant. 


(>4~('n 


Fig.  490. — Directions  for  Making  Ewin  Perineal  Sheet. 

The  sheet  for  vaginal  operations  performed  in  the  dorsal  position  is  made  84  inches  long  by 
64  inches  wide.  One  end  is  folded  so  that  the  corners  marked  c  join  c  on  each  side,  and  the  seams 
are  closed,  thus  forming  a  pocket.  The  opening  for  the  vxilva  should  be  6  inches  long,  2\  inches 
wide  at  the  bottom,  If  inches  wide  at  the  top.  The  lower  facing,  from  a  to  h,  is  made  double,  to 
give  a  thicker  covering  over  the  anus.  The  edges  of  the  opening  are  finished  with  a  narrow  bind- 
ing. From  the  top  of  the  opening,  on  the  under  side,  fasten  a  strap,  10  inches  long  by  2  inches 
wide,  in  the  manner  indicated  by  the  dotted  line  on  the  diagram. 

To  cover  the  patient,  gather  the  top  edge  of  the  pocket  in  one  hand,  and  cover  the  feet  so 
that  the  toes  of  each  foot  come  into  the  corner  of  the  pocket,  care  being  taken  to  locate  the  open- 
ing directly  over  the  vulva.  The  strap  on  the  under  side  must  be  pinned  securely  to  the  patient's 
night-dress.    The  sheet  is  tucked  well  under  the  buttocks,  the  long  end  being  left  to  cover  the  pad. 

This  method  of  holding  the  perineal  position  is  maintained  throughout  the 
operation,  and  is  in  our  experience  superior  to  the  use  of  the  posts  and  stirrups 
with  which  operating  tables  are  usually  equipped.  With  the  patient  in  the 
perineal  position,  an  assistant  scrubs  the  vulva,  vagina,  anus,  and  adjacent  parts 
of  the  thighs  and  buttocks  with  sterile  soap  and  water,  rinsing  off  the  external 
parts  with  sterile  water  and  alcohol. 

A  specially  constructed  perineal  sheet  is  draped  over  the  legs  of  the  patient. 


g44  GYNECOLOGY 

Numerous  forms  of  sheets  for  this  purpose  have  been  devised.     One  of  these 
which  we  have  found  very  convenient  is  depicted  in  Fig.  490. 

The  surgeon's  assistant  stands  at  the  patient's  left,  maintaining  the  position 
of  the  left  leg  by  holding  the  knee  under  his  right  axilla.  In  this  way  the  assist- 
ant has  both  his  hands  free  for  helping  the  surgeon. 

In  like  manner  a  nurse  stands,  at  the  right  of  the  patient,  holding  the  right 
leg  in  the  same  way  and  acting  as  second  assistant  to  the  surgeon.  At  the 
surgeon's  right  is  the  suture  and  instrument  table  presided  over  by  a  nurse  whose 
sole  duty  it  is  to  place  the  necessary  suture  or  instrument  in  the  hand  of  the 
surgeon.  This  rather  elaborate  system  of  assistance  is  provided  in  order  to 
secure  as  much  speed  as  possible  for  operations  which  at  best  are  rather  tedious 
and  time-consuming.  Inasmuch  as  plastic  operations  must  in  the  majority  of 
cases  be  combined  with  a  laparotomy,  every  effort  should  be  made  to  shorten 
the  time  taken  in  their  performance.  This  is  best  accomphshed  by  carrying  out 
the  steps  of  a  given  operation  in  the  same  way  each  time,  and  by  having  a  team 
of  assistants  who  are  thoroughly  famihar  with  the  technic  of  the  surgeon. 

Suture  Material. — In  most  cases  where  sutures  are  required  inside  the  vaginal 
canal  catgut  is  employed.  There  is  divided  opinion  among  operators  as  to  the 
comparative  merits  of  plain  or  chromicized  gut.  Our  experience  has  led  us  to 
discard  the  plain  gut  and  to  use  the  chromicized  form  exclusively.  For  ap- 
proximating vaginal  surfaces  No.  1  is  the  most  useful  size  and  is  emploj^ed  in  the 
operations  of  tracheloplasty,  amputation  of  the  cervix,  anterior  colpoplasty,  and 
perineoplasty.  In  closing  vaginal  wounds  the  stitches  should  always  he  inter- 
rupted. Running  stitches  are  used  only  in  closing  the  deep  layers  in  operations 
for  fistula  in  which  the  tissues  are  split  into  separate  planes,  stitches  of  this  kind 
being  always  buried.  Sutures  that  are  to  be  buried  should  not  be  larger  than 
No.  0  or  No.  00. 

In  fistula  cases,  both  those  of  the  bladder  and  rectum,  it  is  best  to  unite  the 
vaginal  mucous  membrane  with  interrupted  silver  wire,  even  in  those  cases  in 
which  the  wounds  are  closed  in  different  planes. 

In  sewing  up  wounds  external  to  the  vaginal  orifice  experience  has  taught 
us  that  silkworm  gut  is  the  best  suture  material,  though  many  operators  have 
discarded  it  in  favor  of  catgut,  on  account  of  the  necessity  of  removing  the 
stitches.  When  silkworm  gut  is  used  the  best  method  of  protecting  the  ends  is 
to  clamp  them  in  perforated  shot,  for  by  this  means  the  stitches  can  be  kept  very 
clean  and  are  prevented  from  causing  discomfort  by  pricking  the  skin  of  the 
patient. 

Denudation. — All  plastic  operations  involve  a  certain  amount  of  denuda- 
tion of  the  epithehal  surfaces.  Denudation  of  the  cervical  mucous  membrane  in 
the  operation  of  tracheloplasty  is  most  easily  done  with  a  sharp  scalpel.  In  the 
operations  of  anterior  colpoplasty  and  perineoplasty  the  vaginal  mucous  mem- 
brane may  be  removed  either  by  the  ''splitting"  of  a  flap  of  membrane  from  the 
underlying  tissue,  or  by  removal  of  the  membrane  in  narrow  strips  with  Emmet's 


TECHNIC  845 

scissors.  We  greatly  prefer  the  latter  technic.  The  flap-splitting  method  causes 
more  bleeding,  entails  a  greater  loss  of  tissue,  and  even  in  the  hands  of  an  expert 
operator  is  associated  with  the  danger  of  perforating  the  wall  of  the  bladder  or 
rectum.  In  some  cases  the  plane  of  cleavage  between  vaginal  mucous  mem- 
brane and  the  underlying  bladder  or  rectum  is  found  easily  enough  and  the 
layers  can  be  rapidly  and  safely  separated,  but  if  the  tissues  are  thinned  out  by 
tension  or  atrophy  the  separation  may  be  difficult,  bloody,  and  dangerous  to  the 
hollow  organ  beneath.  We  therefore  recommend  to  the  beginner  the  adoption 
of  the  classic  technic  of  Emmet-^'.  e.,  denudation  of  the  tissues  with  scissors. 
With  a  httle  practice  the  membrane  can  be  removed  rapidly  and  entirely  without 

danger. 

In  making  a  denudation  it  is  important  that  the  edges  of  the  area  should 
be  smoothly  cut.  In  order  to  accomphsh  this  it  is  a  good  plan  to  pick  up  with 
tenacula  the  ends  of  the  hne  to  be  cut.  By  drawing  the  tenacula  in  opposite 
directions  the  membrane  is  brought  up  into  a  sharp  fold  or  ridge,  which  may  be 
smoothly  trimmed  off  with  scissors  (see  Operation  for  Perineoplasty). 

Coaptation —The  success  of  plastic  surgery  of  the  vagina  depends  to  a  great 
extent  on  the  ability  of  the  operator  to  secure  accurate  coaptation  of  the  wound 
edges  without  undue  tension.  In  order  to  accomplish  this  the  greatest  care 
should  be  taken  in  making  the  denudation,  that  the  wound  edges  when  coap- 
tated  shall  fit  perfectly  without  wrinkling  and  puckering  of  the  tissues.  This 
requires  a  good  eye  for  symmetry  and  proportion  on  the  part  of  the  operator. 

Wounds  in  which  the  edges  have  been  skilfully  approximated  heal  rapidly 
by  first  intention,  whereas  wounds  in  which  the  coaptation  is  clumsy  and  ragged 
invariably  heal  by  granulation  and  the  formation  of  permanent  scar  tissue. 
As  has  been  emphasized  in  the  section  on  Plastic  Surgery,  m.any  of  the  unpleasant 
after-results  from  operations  on  the  vagina  are  the  result  of  the  contraction  of  old 
cicatrices. 

After-care  of  Plastic  Cases 

The  patient  is  encouraged  to  urinate  within  a  few  hours  after  operation. 
When  an  operation  for  cystocele  has  been  performed  it  is  important  that  the 
bladder  should  not  become  distended.  For  the  first  two  days  it  should  not  be 
allowed  to  accumulate  over  5  ounces  of  urine.  Fortunately,  most  patients  who 
have  had  cystocele  operations  are  soon  able  to  urinate  voluntarily.  They  should 
be  made  to  empty  the  bladder  every  four  hours  for  the  first  two  days  and  at 
night  should  be  wakened  for  this  purpose.  If  the  patient  is  unable  to  pass  her 
water  voluntarily  she  must  be  catheterized  at  regular  intervals.  If  the  cathe- 
terization is  carried  out  in  the  following  manner  (described  also  on  page  268) 
there  is  practically  no  danger  of  causing  a  cystitis:  A  sterile  glass  catheter  is 
attached  to  a  fountain  syringe  suppUed  with  sterile  water.  The  sterile  water 
at  low  tension  is  allowed  to  flow  through  the  catheter  and  cleanse  the  vestibule 
and  surrounding  parts  of  the  vulva.     The  catheter  is  then  introduced  into  the 


846  GYNECOLOGY 

meatus  while  the  water  is  still  flowing.  When  the  end  of  the  catheter  reaches 
the  middle  of  the  urethra  the  water  from  the  fountain  syringe  is  shut  off  and  the 
rubber  tube  of  the  syringe  detached  from  the  catheter.  The  catheter  is  then 
passed  into  the  bladder  and  the  urine  withdrawn. 

When  a  patient  has  had  an  operation  for  vesicovaginal  fistula  it  is  of  still 
greater  moment  that  the  bladder  be  not  distended  with  urine.  These  patients 
for  the  first  four  days  should  void  every  four  hours,  or  if  voluntary  urination 
is  impossible  they  should  be  catheterized.  After  the  second  day  the  intervals 
between  voiding  may  be  somewhat  longer.  Most  patients  who  have  had  opera- 
tions for  vesical  fistulas  are  able  soon  to  urinate  voluntarily.  It  is  a  good  plan,, 
however,  to  catheterize  such  patients  at  least  once  a  day,  for  many  of  them' 
retain  a  certain  amount  of  residual  urine. 

In  none  of  our  cases,  either  for  cystocele  or  for  vesical  fistula,  do  we  employ 
constant  drainage. 

Catharsis. — On  the  morning  following  a  plastic  operation  the  patient  is 
given  I  ounce  of  Epsom  salts,  and  in  the  course  of  three  or  four  hours  a  low  soap- 
suds enema,  except  after  operations  involving  the  sphincter  or  rectum.  At 
night  the  patient  receives  a  compound  rhubarb  pill  (gr.  v)  and  on  the  follow- 
ing morning  an  enema,  whether  she  has  a  voluntary  movement  or  not.  The 
cathartic  pill  at  night  and  enema  in  the  morning  are  repeated  daily  as  a 
routine  during  the  rest  of  the  patient's  stay  in  the  hospital.  In  some  cases, 
especially  in  private  practice  where  there  is  great  objection  to  the  taking  of 
enemas,  this  treatment  must  be  modified  somewhat  by  adding  other  cathar- 
tics. The  results,  however,  are  not  as  satisfactory  as  when  the  above  routine- 
procedure  is  carried  out. 

After  operations  for  complete  tear  we  are  not  accustomed  to  move  the  bowels 
for  nine  days.  Patients  who  have  had  this  operation  require  the  most  unremit- 
ting care  and  expert  nursing.  Every  effort  is  made  to  prevent  a  movement  of 
the  bowels,  and  for  this  reason  the  patient  is  kept  on  a  restricted  liquid  diet 
without  milk,  though  oysters,  eggs,  and  jellies  of  various  kinds  are  occasionally 
permitted.  If  there  is  active  peristalsis  the  patient  may  be  given  15  drops  of 
tincture  of  opium. 

The  bowels  are  moved  on  the  ninth  day  by  giving  1  ounce  of  castor  oil  fol- 
lowed in  a  few  hours  by  a  low  oil  enema  (cottonseed  oil,  4  ounces).  After  the 
first  movement  the  bowels  are  treated  in  the  same  manner  as  in  other  plastic 
cases. 

Care  of  the  Stitches.- — Much  of  the  success  of  a  plastic  operation  depends  on^ 
the  care  of  the  stitches,  for  any  neglect  of  them  is  sure  to  be  followed  by  sepsis. 
The  first  duty  of  the  nurse  is  to  irrigate  the  stitches  after  each  urination  or 
defecation  with  sterile  water  and  to  apply  each  time  a  fresh  sterile  pad  to  the 
parts. 

In  the  treatment  of  the  vaginal  stitches  two  methods  are  in  vogue :  one  by 
which  the  stitches  are  let  alone  and  the  other  by  which  they  receive  frequent 


TECHNIC  847 

cleansing  douches.  These  may  be  called  the  dry  and  wet  methods.  We  are 
very  much  in  favor  of  the  wet  method,  which  is  as  follows : 

On  the  day  following  the  operation  vaginal  douches  of  sterile  water  are  given, 
two  each  day.  This  is  continued  throughout  the  convalescence.  If  at  the  time 
of  leaving  the  hospital  there  is  any  leukorrheal  discharge  present,  as  there 
sometimes  is  as  a  result  of  irritation  from  stitches  not  yet  absorbed,  the  patient 
is  advised  to  take  a  douche  each  day  or  every  other  day  for  a  week  or  two  after 
reaching  home.  If  silkworm-gut  stitches  have  been  used  in  sewing  up  the  ex- 
ternal part  of  the  perineum,  they  should  be  removed  on  the  ninth  day,  after 
which  the  patient  is  allowed  to  sit  up.  Her  usual  stay  in  the  hospital  is  from 
twelve  to  fifteen  days. 

By  treating  the  wounds  in  the  above  way  sepsis  is  very  unusual  in  the  ordinary 
plastic  cases.  Operations  for  complete  tear,  involving  as  they  do  the  anus  and 
rectum,  are  more  frequently  comphcated  by  sepsis  on  account  of  the  impossibility 
of  keeping  the  wounds  perfectly  clean.  The  sepsis  usually  takes  the  form  of  a 
small  locahzed  stitch  abscess  which  discharges  and  then  heals  rapidty,  occa- 
sionally causing  a  ixiinute  temporary  fistula.  It  rarely  affects  the  ultimate  func- 
tional result  of  the  operation. 

Stitch  abscesses  during  the  first  stage  are  best  treated  by  hot  applications 
of  sterile  salt  solution,  changed  very  frequently.  Treated  in  this  way  the  in- 
fections remain  localized  and  often  disappear  without  suppuration.  If  suppu- 
ration occurs  the  hot  apphcations  are  continued  until  the  pu^  discharges  spon- 
taneously. Once  or  twice  each  day  the  small  abscess  is  forcibly  evacuated 
through  the  small  opening  by  pressure  with  the  fingers.  With  careful  attention 
and  cleanliness  the  wound  soon  heals  without  injuring  the  result  of  the  operation. 

Silver  wire  stitches  used  in  operations  for  fistula  are  treated  as  other  vaginal 
stitches.    They  are  not  removed  for  two  or  three  weeks. 


NDEX 


Abbe's  operation  for  carcinoma  of  rectum, 

430 
Abderhalden's  test  for  pregnancy  and  cancer, 
110 
in  differential  diagnosis  of  uterine  my- 
oma and  pregnancy,  324 
Abdomen,  fatty,  ovarian  cyst  and,  differen- 
tiation, 416 
lateral  wall,  cellulitis  in,  260 
operations  on,  length  of  stay  in  bed,  842 
preparation  for,  835 
support  after,  842 
suture  material,  838 
technical  detail,  836 
treatment  after,  840 
palpation  of,  831 
Abdominal  bands,  172.       See  also  Intestinal 
bands. 
cavity,  sponge  in,  837 
hernia,  500 

operation  for,  775 
myomectomy,  750,  751 
operation  for  anteflexion  of  uterus,  695 
ptosis,  158.     See  also  Enter optosis. 
support  after  abdominal  operations,  842 
tumors,  vitiligo  associated  with,  97 
wall,  operations  on,  768 
wound,  suture  of,  839 
Abortion,  tubal,  508 
treatment,  514 
Abscess,  ischiorectal,  280 
of  Bartholin's  gland,  185 

treatment,  operative,  588 
of  kidney,  273 
perim-ethral,  262 

stitch,  in  plastic  operations,  treatment,  847 
tubo-ovarian,  196,  253 
Absence  of  Fallopian  tubes,  445 
of  ovaries,  445 
of  uterus,  441 
of  vagina,  444,  535 

Baldwin's  operation  for,  670 
Graves'  operation  for,  667 
operations  for,  667 
ovaries  and,  55 
Schubert's  operation  for,  670 
54 


Absence  of  vagina,  treatment,  540 
Accessory  organs  of  Zuckerkandl,  85 

ovary,  445 
Acetone  in  carcinoma  of  cervix,  362 
Acid,  benzoic,  in  cystitis,  269 
boric,  in  cystitis,  270 
trichloracetic,  in  dysmenorrhea,  520 
Acne  and  menstruation,  relation  between,  96 

at  puberty,  96 
Acromegaly  from  hyperfunction  of  hypoph- 
ysis, 77 
influence  of  suprarenal  cortex  in,  88 
Adams- Alexander  operation  for  retroversion 

of  uterus,  689 
Addison's  disease  and  genitalia,  relation  be- 
tween, 89 
Adenocarcinoma  of  cervix,  336,  337 
of  endometrium,  362 
of  uterus,  362 

sarcoma  and,  differentiation,  331 
Adenocarcinomatous  degeneration  of  uterine 

myoma,  319 
Adenoma  hidradenoides  vulviE,  287 
of  endometrium,  250 
of  rectum,  431 
Adenomyoma  of  Fallopian  tubes,  421 
of  parovarium,  419 
of  rectovaginal  septum,  305 
of  round  ligament,  423 
of  uterus,  327 
of  vagina,  305 
Adenomyositis  of  uterus,  327 
Adenosarcoma  of  parovarium,  419 

of  uterus,  330 
Adhesions,  attic,  173 

pelvic,    after    gonorrheal    salpingitis,   202. 

See  also  Pelvic  inflammation,  chronic. 
peritoneal,  153 

from  bacterial  peritonitis,  153 
from  chemical  injury,  154 
from  mechanical  injury,  154 
from  surface  necrosis,  155 
from  tuberculosis,  154 
traumatic,  154 
traumatic,  from  retroversion  of  uterus,  462 
Adiposity  after  remoA'al  of  ovaries,  52,  53,  54 

849 


850 


INDEX 


Adiposity  as  cause  of  sterility,  533 
Adrenalin,  85 

function  of,  85,  86 
in  dysmenorrhea,  519 
in  hemophilia,  107 

secretion  of,  effect  of  emotions  upon,  86 
Adrenin,  85 

Albarran's  modification  of  Braquehaye's  op- 
eration for  vesicovaginal  fistula,  657,  659 
Albuginea  of  ovary,  32 
Alexander-Adams  operation  for  retroversion 

of  uterus,  689 
Alexander's    operation    for    retroversion    of 
uterus,  466,  688 
internal,  for  retroversion  of  uterus,  683 
Allingham's  operation  for  hemorrhoids,  819 
Alpha  ray,  349 
Amenorrhea,  571 

castration  as  cause,  571 

disturbances  of  glands  of  internal  secretion 

as  cause,  572 
etiology,  571,  572 
functional,  572 

ovarian  deficiency  and,  56 
extract  in,  65 
in  constitutional  diseases,  572 
neuroses  from,  123 

of  young  women,  transplantation  of  ova- 
rian tissue  in,  64 
of  youth,  523 
placental  extracts  in,  65 
tuberculosis  and,  relationship,  572 
Amoeba  urogenitalis,  238 
Amphimixis,  24 
Amputation  of  cervix,  599 

and  anterior  colpoplasty  combined,  620 
Hegar's  operation,  599,  604 
of  uterus,  713.     See  also  Hysterectomy. 
Anal  fissure,  282 
treatment,  283 
fistula,  281 

Elting's  operation,  827 
Graves'  operation,  824-827 
operations  for,  824 
treatment,  282 
Anaphrodism,  138 
Anastomosis,  ureteral,  810,  811,  812 
Anemic  heart,  114 
Anesthesia,  sexual,  134,  136,  138 
Angioma,  papillary,  of  vestibule,  293 
Angiomatous  degeneration  of  uterine  myoma, 

315 
Angiosarcoma  of  uterus,  330 
Anteflexion  of  cervix,  pessaries  for,  691 
of  uterus,  455,  480 

abdominal  operation,  695 


Anteflexion  of  uterus,  Baker's  operation,  693 
diagnosis,  481 
Dudley's  operation,  694 
etiology,  481 
Graves'  operation,  695 
operations  for,  691 
pessaries  for,  481,  691 
Pozzi's  operation,  693 
suspension  operation,  482 
symptoms,  481 
treatment,  481 
Anteposition  of  uterus,  456 
Anteversion  of  uterus,  455 
Antigonococcic  serum,  215 

vaccines,  215 
Antitoxin,  diphtheria,  in  cystitis,  269 
Anus,  atresia  of,  449 
imperforate,  449 
prolapse  of,  431 
vaginal,  451 
vestibular,  451 
Appendicitis,  acute  gonorrheal  salpingitis  and, 
differentiation,  206 
and  movable  kidney,  association,  170 
chronic,    and    menstruation,    relation    be- 
tween, 146 
during  labor,  147 

pregnancy,  146,  147 
relation  of  genitalia  to,  145-147 
Appendiculo-ovarian  ligament,  145,  173 
Appendix,  retroperitoneal,  172 

vermiform,  relation  of  genitalia  to,  145 
Apron  incision  in  fistula  in  ano,  825 
Arbor  vitse,  438 
Argyrol  in  cystitis,  270 
Arteriosclerosis,  115 

as  cause  of  uterine  hemorrhage,  116,  117 
Artificial  impregnation  in  sterility,  566 
vagina,  Baldwin's  method  of  making,  670 
Graves'  method  of  making,  667 
method  of  making,  444,  667 
Schubert's  method  of  making,  670 
Ascites    after    operation    for    ovarian    cysts, 
treatment,  417 
associated  with  cancerous  cysts  of  ovary, 
415 
with  fibroma  of  ovary,  410 
with  ovarian  tumors,  412 
cysts  of  ovary  and,  differentiation,  415 
txibercular  peritonitis  with,  221 
Aspermatism,  556 
Atresia  of  anus,  449 
of  cervical  canal,  543 
of  follicle,  40,  382 
cystic,  42 
during  pregnancy,  41 


INDEX 


851 


Atresia  of  follicle,  manner  of  taking  place,  41 
obliterating,  42 
of  hymen,  536 

treatment,  539 
of  rectmn,  449 
of  uterus,  444 

of  vagina,  535.     See  also  Gynatresia. 
Atroph}',  genital,  540 

cancer  and,  differentiation,  546 
complications,  543 
diagnosis,  546 
due  to  castration,  543 

to  constitutional  diseases,  543 
etiology,  543 
treatment,  546 
lactation,  543 

of  ovaries,  56 
of  bladder,  545 
of  cer\'ix,  541 
of  Fallopian  tube,  541 
of  labia  majora,  542 

minora,  542 
of  ovary,  56,  542 

as  cause  of  changes  during  menopause,  23 
pathologic,  56 
of  urethra,  545 
of  uterine  fibroids,  316,  317 
of  uterus,  541 
of  vagina,  542 
Atropin  in  dysmenorrhea,  519 
Attic  adhesions,  173 
Auerbach's  plexus,  151 
Ausf  aUserscheinimgen  ,114 
Azoospermia,  556 

Backache,  156 

in  carcinoma  of  cervix,  579 

in  malposition  of  uterus,  579 

in  retroflexion  of  uterus,  577 

in  retroversion  of  uterus,  463 
due  to  adhesions,  469 
Bacteria  as  cause  of  cystitis,  262,  263 
routes  of  infection,  263 
of  pyeUtis,  273 

mode  of  entrance,  into  bladder,  262,  263 
to  kidney,  273 
Bacterial  peritonitis,  153 
Baker's  operation  for  anteflexion  of  uterus, 

693 
Baldwin's  operation  for  absence  of  vagina, 

670 
Baldy's  operation  for  retroversion  of  uterus, 

685 
Baldy-Webster  operation  for  retroversion  of 

uterus,  468,  685 
Ball  myoma  of  uterus,  310 


Bands,  ileopehac,  173 

intestinal,  172.     See  also  Intestinal  bands. 
Bardenheuer's  incision,  768 
Bartholinitis,  gonorrheal,  184 

treatment,  185 
Barthohn's  glands,  abscess  of,  185 
treatment,  operative,  588 
carcinoma  of,  292 
cysts  of,  186,  292 
treatment,  187 
operative,  588 
gonorrheal  inflammation,  184 

treatment,  185 
operations  on,  588 
Bartlett's  method  of  transplantation  of  fascia 

for  postoperative  hernia;,  783 
Basedow's  disease.     See  Exophthalmic  goiter. 
Basset's  method  of  dissection  of  inguinal  re- 
gions in  carcinoma  of  vulva,  584,  585 
Bearing-dowTi  feehngs,  579 
Bed,  length  of  stay  in,  in  abdominal  opera- 
tions, 842 
BeU's   method    of   stomatoplastic   salpingos- 
tomy, 762 
Benzoate  of  soda  in  cystitis,  269 
Benzoic  acid  in  cystitis,  269 
Beta  ray,  349 

Beyea's  operation  for  enteroptosis,  165 
Bichlorid  of  mercury  in  pyelitis,  277 
Bicornuate  uterus,  442 

double,  with  double  vagina,  441 
Bilharzia  hEematobia  of  vulva,  238 
Bladder,  atrophy  of,  545 
calculus  of,  428 
diagnosis,  429 
treatment,  429 
capacity  of,  diminished,  265 
carcinoma  of,  427.     See  also  Carcinoma  of 

bladder. 
cysts  of,  265 
defects  of,  445 
drainage,  in  cj^stitis,  270 
exstrophy  of,  446,  447 

treatment,  449 
fissure  of,  inferior,  449 

superior,  448 
fistula  of,  498.     See  also  Fistula,  vesical. 
gangrene  of,  265 

gradual  dilatation,  for  limited  capacity,  270 
implantation  of  ureter  in,  812 
inflammation  of,  262.     See  also  Cystitis. 
irritable,  in  retroversion  of  uterus,  464 
mode  of  entrance  of  bacteria  into,  262,  263 
operations  on,  815 

pelvic  cellulitis  after,  260 
papilloma  of,  426  i 


852 


INDEX 


Bladder,  papilloma  of,  treatment,  428 
relation  of  genitalia  to,  141,  142 
stone  in,  428 
syphilis  of,  272 
tuberculosis  of,  271 
diagnosis,  271 
treatment,  271 
tumors  of,  426 
symptoms,  428 
treatment,  428 
ulcer  of,  265 
wall,  sloughing,  265 
Blastomeres,  406 

Blood,  appearance  of,  after  menorrhagia,  109 
after  metrorrhagia,  109 
coagulability  of,  influence  of  uterine  and 

ovarian  extracts  on,  58 
extravasation  of,  leukocytosis  after,  109 

regeneration  of  blood  after,  109 
in  chlorosis,  106 
menstrual,  105 
amount  lost,  20 
non-coagulabilitjr  of,  20,  105 
regeneration  of,  after  hemorrhage,  108,  109 
relation  of  genitalia  to,  105 
serum  in  menorrhagia  of  youth,  525 
transfusion  in  hemophilia,  107 
in  menorrhagia  of  youth,  525 
Blood-cysts  of  ovary,  386 
Bloodless  fold  of  Treves,  172 
Blood-pressure,  113 

Blood-vessels,   pelvic,   congestion   of,   during 
menstruation,  20 
relation  of  genitalia  to,  115 
Bones  and  joints,  relation  of  genitalia  to,  156 
Boric  acid  in  cystitis,  270 
Bowels,  postoperative  treatment,  840,  841 
Braquehaye's     operation    for.  vesicovaginal 
fistula,  657 
Albarran's  modification,  657,  659 
Breasts  and  ovaries,  relation  between,  94 
condition  of,  during  menstruation,  20 
development  of,  at  puberty,  18 
enlargement  of,  at  birth,  18 

during  menstruation,  18 
influence  of  placenta  on,  94 
relation  of  genitalia  to,  93 
Broad  ligament,  fibromyoma  of,  424 

varicose  veins  in,  119 
Brodel  stitch,  803 

Buboes  after  soft  chancre  of  vulva,  225 
Byrne's  treatment  of  carcinoma  of  cervix,  360 

Cachexia  in  carcinoma  of  cervix,  344 

strumipriva,  82 
Calcification  of  uterine  myoma,  316 


Calcium  chlorid  in  hemophilia,  107 

in  menorrhagia  of  youth,  525 
Calculus,  vesical,  428 

diagnosis,  429 

treatment,  429 
Callous  stenosis  of  cervix,  555 
Canal  of  Nuck,  cyst  of,  292 
Cancer.     See  Carcinoma. 
Capsule,  Gerota's,  799 
Carcinoma,  Abderhalden's  test  for,  110 
as  cause  of  sterility,  558 
of  Barthohn's  gland,  292 
of  bladder,  427 

secondary,  427 
of  cervix,  334 

age  incidence,  339 

backache  in,  579 

bleeding  in,  342 

cachexia  in,  344 

curetage  for,  593 

diagnosis,  344 

elevation  of  temperature  in,  343 

etiology,  339 

heat  treatment,  360 

in  poor  and  ill-nourished,  342 

incidence,  339 

infection  of  lymph-glands,  345 

invertent,  336,  338 

Kronig's  operation,  361 

lacerated  cervix  and,  differentiation,  486 

leukorrhea  in,  342,  570 

mesothorium  in,  348 

metastasis,  343 

metrorrhagia  in,  576 

operability,  346 

operative  treatment,  347 

pain  in,  343 

palliative  treatment,  361 

parametritis  and,  differentiation,  259 

pathology,  335 

Percy's  treatment,  360,  790 

prognosis,  344 

radium  in,  348,  362 

details  of  treatment,  355 
Graves'  technic,  792 
selection  of  cases  for,  353 

removal  of  specimen  for  diagnosis,  345, 
346 

Schauta's  operation,  744-750 

squamous-cell,  335 

starting  points,  337 

symptoms,  342 

treatment,  medical,  348 
operative,  347 
palliative,  361 

vaginal  discharge  in,  342 


INDEX 


853 


Carcinoma  of  cervix,  vaginal  hysterectomy 
for,  744-750 
Wertheim's  operation,  731-744 
x-rays  in,  348 
of  clitoris,  296 
of  Fallopian  tubes,  420 
diagnosis,  421 
etiology,  420 
prognosis,  421 
treatment,  421 
of  ovary,  398,  404 
classification,  398 
colloid,  405,  406,  407 
cystic,  398 
metastatic,  399 
secondary,  399 
solid,  398 
of  parovarium,  419 
of  rectum,  429 
diagnosis,  430 
prognosis,  430 
symptoms,  429 
treatment,  430 
of  uterus,  362 

age  incidence,  364 

associated  with  fibroids,  366,  367 

bleeding  in,  366,  367 

diagnosis,  368 

fibroid  and,  differentiation,  323 

genital  atrophy  and,  differentiation,  546 

gland  hyperplasia  of  endometrium  and, 

differentiation,  368 
in  well-to-do,  342 
increase,  339 
metastasis,  364 
metrorrhagia  in,  576 
treatment,  370 

Wertheim's  operation,  731-744 
of  vagina,  297 
diagnosis,  297 
prognosis,  298 
treatment,  298 
of  vulva,  287 
diagnosis,  289 

Taussig's  operation  for,  291,  584 
treatment,  290 
operative,  584 
Carcinomatous  degeneration  of  ovarian  cysts, 
398 
of  uterine  myoma,  319 
Carotid  gland,  85 
Caruncle,  urethral,  293 
Castration.     See  Ovariectomy. 
Catamenia.     See  Menstruation. 
Catarrh,  nasal,  at  menopause,  100 
Catarrhal  salpingitis,  193 


Catharsis,  postoperative,  in  abdominal  cases, 
840,  841 
in  plastic  cases,  846 
Catheterization  as  cause  of  cystitis,  263 
Cautery  in  rectal  prolapse,  432 

Percy's,  for  carcinoma  of  cervix,  361,  790 
Cecum  mobile  of  Wilms,  159,  169 

movable,  and  movable  kidney,  influence  be- 
tween, 169 
Cells,  germ-,  439 
interstitial,  48-51 
Langhans',  372 
lutein,  39 
of  Leydig,  48 
somatic,  407 
theca-lutein,  387 
function  of,  50 
Cellular  tissue,  paracystic,  256 
parametrial,  256 
paraproctal,  256 
pelvic,  anatomy  of,  255 

inflammations  of,  256.     See  also  Para- 
metritis. 
Cellulitis,  pelvic,  255 

after  operations  on  bladder,  260 
in  lateral  wall  of  abdomen,  260 
Cervical  canal,  atresia  of,  543 
Cervicitis,  241 
symptoms,  242 
treatment,  242 
Cervix,  adenocarcinoma  of,  336,  337 
amputation  of,  599 

and  anterior  colpoplasty  combined,  620 
Hegar's  operation,  599,  604 
anteflexion  of,  pessaries  for,  691 
atrophy  of,  541 
callous  stenosis,  555 
carcinoma  of,  334.     See  also  Cardnovia  of 

cervix. 
curetage  of,  592 
dilatation  of,  591 
ectropion  of,  336,  341 
elongation  of,  in  procidentia  of  uterus,  477 
epithelioma  of,  335,  336 
erosion  of,  241,  336,  341,  485 

operative  treatment,  593 
eversion  of,  336 

operative  treatment,  593 
fibroids  of,  310,  311  ,       , 

glands  of,  189 

hypertrophy  of,  after  lacerated  cervix,  485 
laceration  of,  485.     See  also  Laceration  of 

cervix. 
plastic  surgery,  593 

polyps  of,  332.   See  also  Polyps,  cervical. 
tuberculosis  of,  220 


854 


INDEX 


Cervix,  ulceration  of,  336,  485,  486 

Chamberlain's  pessary,  692 

Chancre,  soft,  of  vulva,  224 

Character,  influence  of  masturbation  on,  132, 

136 
Child-bearing,  influence  of,  on  size  and  weight 

of  uterus,  17 
Childbirth,  injuries  due  to,  485 
Chloasma  gravidarum,  97 
Chlorosis,  106 

and  genital  system,  relation  between,  106 
blood-picture  in,  106 
CholeUthiasis,  148.    See  also  Gall-stones. 
Chorio-epithehoma  malignum,  370 

and   trophoblast,    biologic   resemblance, 

375 
bleeding  in,  376 
histology,  372 
metastasis,  377 
metrorrhagia  in,  575 
parametrial  infiltration  in,  380 
spontaneous  healing,  380 
symptoms,  376 

theca-lutein  cysts  associated  with,  387 
treatment,  378 
of  Fallopian  tube,  421 
of  vagina,  299 
Chromaffin  system,  85,  86 
Chromophils,  73 
Chromophobes,  73 

Circulation,    deficient,    of  genitalia,    ovarian 
extract  in,  65 
organs  of,  relation  of  genitaha  to,  112 
Circulatory    system,    condition    of,    during 

menstruation,  21 
Clamp    and    cautery    operation    for   hemor- 
rhoids, 822 
Clark's  perineoplasty,  633 
for  complete  tear,  636 
technic  of  anterior  colpoplasty,  617 
Climacteric,  22.     See  also  Menopause. 
Climate,  effect  of,  on  menopause,  19 

on  occurrence  of  menstruation,  18,  19 
Clitoris,  carcinoma  of,  296 
hypertrophy  of,  295,  296 
tumors  of,  295 
Cloaca,  441 
Coagulability  of  blood,  influence  of  uterine 

and  ovarian  extracts  on,  58 
Coagulation  of  menstrual  blood,  prevention, 

20,  105 
Coaptation  of  wound  edges  in  plastic  surgery, 

845 
Cocain  in  dysmenorrhea,  520 
Cocainizing    nasal    mucous    membrane,    in- 
fluence of,  on  dysmenorrhea,  100 


Coccygodynia,  580 

Coccyx,  pain  in,  580 

Coffeys'  operation  for  enteroptosis,  165 

for  retroversion  of  uterus,  468 
Coitus,  heart  symptoms  during,  113 
painful,  138,  140 
unpleasant,  534,  535 
Cohc,  uterine,  577 

Colloid  carcinoma  of  ovary,  405,  406,  407 
Colon,  diverticulitis  of,  277.     See  also  Diver- 
ticulitis of  colon. 
implantation  of  ureter  in,  814 
inflammation  of,  277 
Colpitis,  236.     See  also  Vaginitis. 
Colpoplasty,  anterior,  and  amputation  of  cer- 
vix combined,  620 
Clark's  technic,  617 
Graves'  method,  608 
Colpotomy,  vaginal,  675 
anterior,  676 
posterior,  677 
Compact  layer  of  uterine  mucosa,  26 
Complement-fixation    test    in    diagnosis    of 

gonorrheal  salpingitis,  205 
Conception,  physiology  of,  23 
Condyloma  acuminata  of  vulva,  227 

treatment,  228 
Congestion,  premenstrual,  of  uterine  mucosa, 

24 
Connective  tissue,  pelvic,  tumors  of,  423 
Consanguinity  as  cause  of  sterility,  561 
Consciousness,  125 
aware,  125 
unaware,  125 
Constipation  at  menopause,  102 
in  procidentia  of  uterus,  478 
in  retroversion  of  uterus,  464 
Constitution,  hypoplastic,  55 
Constitutional  changes  during  menopause,  22 
diseases,  amenorrhea  in,  572 
as  cause  of  sterility,  560 
genital  atrophy  due  to,  543 
Copaiba,  oil  of,  in  gonococcal  cystitis,  269 
Corpus  albicans,  39 
luteum,  38 

and  interstitial  gland,  reciprocal  relation- 
ship between,  50 
as  organ  of  internal  secretion,  46 
cysts,  385 
formation  of,  38 
macroscopic     appearance,     in     various 

stages,  59 
of  pregnancy,   macroscopic  appearance, 

59 
period  of  regression,  macroscopic  appear- 
ance, 59 


INDEX 


855 


Corpus  luteum,   period  of   ripeness,   macro- 
scopic appearance,  59 
persistence  of,  pregnancy  and,  47 
proliferative  period,  macroscopic  appear- 
ance, 59 
size  of,  39 

vascularization  period,  macroscopic  ap- 
pearance, 59 
Crede's  ointment  in  varicose  ulcer,  830 
Cretinism,  82 
endemic,  83 
Cri  uterine,  592 

Critical  period  of  woman's  life,  23 
Crystallizations  of  resistance,  175 
Cumulus  oophorus,  34 
Curetage  of  cervix,  592 

of  uterus,  592 
Curve  of  Ott,  121 
Cystadenoma  of  ovary,  387 
origin,  396 

pseudomucinous,  389 
origin  of,  397 
treatment,  391 
serous,  393 
origin  of,  396 
of  parovarium,  419 
Cystic  carcinoma  of  ovary,  398 
cystitis,  265 

degeneration  of  ovaries  as  cause  of  sterility, 
558 
of  ovary,  383 
of  uterine  myoma,  314 
follicle  atresia,  42 
sarcoma  of  uterus,  330 
Cystitis,  262 

bacteria  as  cause,  262,  263 
routes  of  infection,  263 
catheterization  as  cause,  263 
course,  266 
cystic,  265 
diagnosis,  266 
diphtheric,  treatment,  269 
etiology,  262-264 
exfoliative,  265 
gonorrheal,  264,  274 
treatment,  269 

urethritis  and,  differentiation,  266 
hematogenous,  264 
in  old  women,  272 
operation  in,  815 
pathology,  264 
polyposa,  265 
prophylaxis,  268 
symptoms,  266,  274 
syphilitic,  272 
treatment,  269 


Cystitis,  tubercular,  271 
treatment,  269 
vegetans,  265 
verrucosa,  265 
vetularum,  272 
Cystocele,  457,  471,  487 
diagnosis,  488 
Graves'  operation  for,  608 
symptoms,  488 
treatment,  489 
Cystogen  in  cystitis,  269 
Cystoma  of  ovary,  387 
Cystostomy,  vaginal,  815 
Dudley's  method,  815 
Kelly's  method,  816 
Cystotomy,  suprapubic,  815 

Kelly's  method,  815 
Cysts,  blood-,  of  ovary,  386 

dermoid,  of  Fallopian  tubes,  421,  423 
of  ovary,  401,  408,  409 
mahgnant  changes,  403' 
parthenogenesis,  405 
of  parovarium,  419 
of  pelvic  connective  tissue,  425 
treatment,  426 
echinococcus,  of  vulva,  292 
nabothian,  191 

of  Bartholin's  glands,  186,  292 
treatment,  187 
operative,  588 
of  bladder,  265 
of  canal  of  Nuck,  292 
of  corpus  luteum,  385 
of  Fallopian  tubes,  421 
of  Graafian  follicle,  381- 
of  ovary,  254,  381 

ascites  after  operation    for,   treatment, 
417 
and,  differentiation,  415 
blood-,  386 

carcinomatous  degeneration,  398 
dermoid,  401,  408,  409 
malignant  changes,  403 
parthenogenesis,  405 
diagnosis,  415 

diastasis  of  recti  muscles  and,  differen- 
tiation, 416 
everting,  389 

fatty  abdomen  and,  differentiation,  416 
follicular,  381 

implantation  metastasis,  389 
inverting,  389 
monolocular,  388 
multilocular,  388 
operation  for,  757 
parvilocular,  388 


856 


INDEX 


Cysts  of  ovary,  prognosis,  417 
pseudomucinous,  388 
origin  of,  397 
treatment,  391 
rupture,  412 
seed  metastasis,  389 
serous,  393 

origin  of,  396 
symptoms,  412 
torsion,  413 

acute  gonorrheal  salpingitis  and,  dif- 
ferentiation, 207 
treatment,  416 
of  parovarium,  418 

treatment,  419 
of  vagina,  299 
diagnosis,  300 
etiology,  300 
treatment,  301 
of  vulva,  sebaceous,  225 
parovarian,  418 

treatment,  419 
perineal,  301 
sebaceous,  of  vulva,  225 
theca-lutein,  387 
tubo-ovarian,  198 

Davenport's  .treatment    of    dysmenorrhea, 

521 
Decidua,  47 

ectopic,  509 
Deciduoma  maUgnum,  370 
Defecation,  pain  on,  581 
Defects,  congenital,  of  uterus,  441 
developmental,  436 

of  ovaries  and  tubes,  445 
of  vagina,  444 
of  bladder,  445 
of  development,  436 
of  urethra,  445 
Degeneration,     carcinomatous,     of     ovarian 
cysts,  398 
of  ovary,  254 
cystic,  254,  383 

as  cause  of  sterility,  558 
small,  254 
of  uterine  myoma,  311.     See  also  Myoma 

of  uterus. 
race,  as  cause  of  sterility,  561 
Denudation  in  plastic  operations,  844 
Dermatosis  dysmenorrhoica  symmetrica,  95 
Dermoid  cysts  of  Fallopian  tubes,  421,  423 
of  ovary,  401,  408,  409 
malignant  changes,  403 
parthenogenesis,  405 
of  parovarium,  419 


Dermoid  cysts  of  pelvic  connective  tissue,  425 
treatment,  426 
plugs,  402 
Descent  of  ovaries,  440 

of  uterus,  457 
Determination  of  sex,  68-72 
Development,  defects  of,  436 
Diarrhea  at  menopause,  102 
during  menstruation,  102 
Diastasis  of  recti  muscles,  500 
operation  for,  771-774 
ovarian  cyst  and,  differentiation,  416 
treatment,  501 
Diathermy   in   chronic   pelvic   inflammation 

with  adhesions,  212 
Diet  in  cystitis,  269 
Digestion,  parenteric,  110 
Digestive  disturbances  at  menopause,  102 
system,  condition  of,  during  menstruation, 

20 
tract,  relation  of  genitalia  to,  100 
Digital  examination  by  vagina,  832 
Dilatation  of  cervix,  591 
Dionin  in  carcinoma  of  cervix,  361 
Diphtheria  and  genitaha,  relation  between, 
157 
antitoxin  in  cystitis,  269 
Diphtheric  cystitis,  treatment,  269 
Discus  proligerus,  34,  36 
Dissection  and  ligation  for  hemorrhoids,  819 
of  ingmnal  regions  for  carcinoma  of  cervix. 
Basset's  method,  584,  585 
Distoma  haematobium  of  vulva,  238 
Diverticula,  intestinal,  277 
acquired,  277,  278 
congenital,  278 
false,  278 
true,  278 
of  urethral  canal,  301 
Diverticuhtis  of  colon,  277 
etiology,  278 
symptoms,  280 
treatment,  280 
of  sigmoid,  acute  gonorrheal  salpingitis  and; 
differentiation,  207 
Double  bicornuate  uterus  with  double  vagina; 
441 
uterus,  442,  443,  444 
Douglas'    pouch,    closure    of,    for    rectocele. 

Graves'  operation,  643 
Drainage  of  bladder  in  cystitis,  270 

vaginal,   after  supravaginal  hysterectomy 
723 
Dudley's    method    of    vaginal    cystostomy 
815 
operation  for  anteflexion  of  \iterus,  694 


INDEX 


857 


Dudley's  operation  for  dysmenorrhea,    520, 

521,  694 
Dwarf  uterus,  554 
Dwarfism  from  hyperfunction  of  hypophysis, 

78 
Dysfunction  of  glands  of  internal  secretion,  45 
Dysmenorrhea,  515 
acquired,  515 
essential,  122,  515 

Davenport's  treatment,  521 
Dudley's  operation,  520,  694 
etiology,  515 

malposition  of  uterus  and,  relation,  517 
nasal  treatment,  520 
Pfannenstiel's  operation,  521 
Pozzi's  operation,  521,  693 
symptoms,  519 
treatment,  519 
nasal,  520 
orthopedic,  521 
surgical,  520 
in  retroversion  of  uterus,  464 
influence  of  cocainizing  nasal  mucous  mem- 
brane on,  100 
membranous,  522 
diagnosis,  523 
etiology,  523 
prognosis,  523 
symptoms,  523 
treatment,  523 
nasal,  517 
neuroses  from,  122 
ovarian,  517 

extract  in,  519 
secondary,  515 
vicarious,  113 
Dyspareunia,  534 
causes,  138-140 
Dyspitmtarism,  78 
Dyspnea  as  result  of  large  pelvic  tumors,  135 

Ear,  relation  of  genitaha  to,  99 
Echinococcus  cyst  of  vulva,  292 
Eclampsia    and    parathyroids,    relation    be- 
tween, 84 
Ectopic  decidua,  509 
pregnancy,  506 

acute  gonorrheal  salpingitis  and,  diiTer- 
entiation,  207 

diagnosis,  512 

etiology,  506 

hematocele  in,  508,  511,  512 

hematoma  in,  508 

hematosalpinx  in,  508 

metrorrhagia  in,  576 

pain  in,  510,  511,  512,  577 


Ectopic  pregnancy,  pelvic  hematocele  in,  508 
rupture  in,  508 

treatment,  513 
symptoms,  510 
treatment,  513 

uterine  bleeding  in,  508,  509,  511 
Ectropion  of  cervix,  336,  341 

of  urethral  mucous  membrane,  545 
treatment,  547 
Eczema  associated  with  pelvic  diseases,  96 
climacteric,  96 
intertrigo  of  vulva,  225 
Edema  of  skin  associated  with  menstruation 

and  climacteric,  96 
Edematous  degeneration  of  uterine  myoma, 

311 
Effluvium  seminis  as  cause  of  sterility,  555 
Ekehorn's    operation    for    rectal    prolapse, 

Tuttle's  modification,  817 
Electricity    in    chronic    pelvic    inflammation 
with  adhesions,  212 
in  dyspareunia,  535 
in  papilloma  of  bladder,  428 
in  stricture  of  urethra,  262 
in  urethral  caruncle,  294 
Elephantiasis  in  Southern  negroes,  230 

of  vulva,  230 
Elongation  of  cervix  in  procidentia  of  uterus, 
477 
of  uterus,  458 
Elting's  operation  for  anal  fistula,  282,  827 
EmboHsm,  postoperative,  118 
Embryologic  development  of  genital  organs, 
436 
of  ovaries,  439 
of  uterus,  436 
of  vagina,  436 
Emmet's  denudation  of  tissues  with  scissors, 
845 
operation  for  complete  laceration  of  peri- 
neum.  Graves'  modification,  647 
for  laceration  of  perineum,  497 
Graves'  modification,  625 
for  rectocele,  Graves'  modification,  625     . 
of  tracheoplasty,  487,  593 
perineoplasty.  Graves'  modification,  625 
Emphysematous  vaginitis,  239 
Enchondroma  of  vulva,  292 
Endemic  cretinism,  83 
Endocervicitis,  241 

as  cause  of  sterility,  557 

treatment,  564 
curetage  of  cervix  for,  593 
gonorrheal,  189 
chronic,  190 
treatment,  191 


858 


INDEX 


Endocervicitis,  Schroder's  operation,  604 

symptoms,  242 

treatment,  242 
Endocervix,  gonorrheal  inflammation,  189 

leukorrhea  from,  191 
Endometritis,  242 

as  cause  of  steriHty,  557 

chronic  interstitial,  247 

dysmenorrhoica,  516 

exfoliative,  522 

fibrinous,  523 

gonorrheal,  192,  245 

infectious,  244 
treatment,  246 

interstitial,  chronic,  247 
radium  in,  528 

postmenstrual  necrobiotic,  248 

radiiim  in,  531 

tubercular,  219 
Endometrium,  adenocarcinoma  of,  362 

adenoma  of,  250 

gland  hyperplasia,   cancer  of  uterus  and, 
differentiation,  368 

gland  hypertrophy,  249 
treatment,  251 

gonorrheal  inflammation,  192 

hj^ertrophy,  249 
treatment,  251 

infections  of,  244 

inflammation  of,  242 

menstruating,  physiologic  anatomy,  24 

polypoid  gland  hypertrophy,  250,  574 

polyps  of,  333,  334 

sarcoma  of,  329 

tuberculosis  of,  219 
Endosalpingitis,  gonorrheal,  193 

tubercular,  216,  217 
EndotheUoma  of  FaUopian  tubes,  421 

of  ovary,  411 

of  rectum,  430 
Enteroptosis,  158 

acquired,  161 

Beyea's  operation  for,  165 

Coffey's  operation  for,  165 

congenital,  162 

diagnosis,  164 

etiology,  158 

predisposing,  160 

Graves'  operation  for,  167 

Lane's  operation  for,  165 

mid-line,  160 

Rovsing's  operation  for,  165 

symptoms,  163 

treatment,  164 
gynecologic,  166 
me'dical,  164 


Enteroptosis,  treatment,  neurologic,  167 
orthopedic,  164 
surgical,  165 
Wihns'  operation  for,  165 
Enterovesical  fistula,  499 
Epinephrin,  85,  86 
Epiphysis,  internal  secretory  action  of,  90,  91 

relation  of,  to  genitalia,  90 
Epispadias,  446,  449 

treatment,  449 
Epistaxis  during  menstruation,  21 
Epithelial  layer  of  primordial  follicle,  33 
Epithehoma  of  cervix,  335,  336 
of  rectimi,  430 
of  vulva,  289 
Epithehum,  germinal,  436 
of  ovary,  31 
peritoneal,  destruction  of,  152,  153 
bacterial  infection  as  cause,  153 
Epoophoron,  439 

Ergot  in  menorrhagia  due  to  uterine  fibroids, 
325 
in  postpartum  hemorrhage,  79 
Erosio  virginis,  570 
Erosion  of  cervix,  241,  336,  341,  485 

operative  treatment,  593 
Erysipelas    and    menstruation,    relation    be- 
tween, 96 
Essential  dysmenorrhea,  122,  515.     See  also 
Dysmenorrhea,  essential. 
symptoms,  568 
Esthiomene  of  vulva,  229 

treatment,  230 
Ether  pneumonia,  103 

rash,  97 
Eimuch,  characteristics  of,  52,  53,  76 
Eversion  of  cervix,  336 

operative  treatment,  593 
Ewin  perineal  sheet,  directions  for  making, 

843 
Examination  of  patient,  831 

in  private  house,  834 
Exanthemata,  menstrual,  95 
ExfoUative  cystitis,  265 

endometritis,  522 
Exophthalmic  goiter,  81 
at  climacteric,  81 

question  of  marriage  and  reproduction  in, 
82 
Exstrophy  of  bladder,  446,  447 

treatment,  449 
Extirpation  of  kidney,  803 

for  injury  of  ureter,  813 
Extra-uterine   pregnancy,    506.         See   also 

Ectopic  pregnancy. 
Extravasation  of  blood,  leukocytosis  after,  109 


INDEX 


859 


Extravasation  of  blood,  regeneration  of  blood 

after,  109 
Eyes,  condition  of,  during  menstruation,  21 

hemorrhage  of,  puerperal  sepsis  as  cause,  99 

relation  of  genitalia  to,  98 

Face,  hair  on,  in  middle  age,  23 
Facies,  ovarian,  412 
Fallopian  tubes,  absence,  445 
adenomyoma,  421 
atrophy,  541 
carcinoma,  420.      See  also  Carcinoma  of 

Fallopian  tubes. 
chorio-epithelioma,  421 
condition  of,  during  menstruation,  20 
cysts,  421 

defects,  developmental,  445 
dermoid  cysts,  421,  423 
endothelioma,  421 
fibroma,  421 
fibromyoma,  421 
fibromyxoma  cystosum,  421 
gonorrheal  inflammation,  192 
in  infantilism  as  cause  of  sterility,  553 
isthmus  of,  gonorrheal  infection,  198 
lymphangioma,  421 
mucous  polyps,  421 
myosarcoma,  423 
operations  on,  757 
papilloma,  421 
sarcoma,  421 
Taussig's  operation  for  sterilization  of, 

762 
tuberculosis,  216 
tumors,  420 
False  vaginismus,  533 
Fascia,  retrorenal,  799 

transplantation  of,  for  postoperative  hernia, 
782 
Bartlett's  method,  783 
Shaw's  principles  of  technic,  786 
Fat,  accumulation  of,  after  removal  of  ovaries, 

52,  53,  54 
Fatty  abdomen,  ovarian  cyst  and,  differen- 
tiation, 416 
degeneration  of  uterine  myoma,  315 
tumors  of  vulva,  287 
Femoral  hernia,  Moschowitz's  operation  for, 

787 
Fetalism  as  cause  of  sterihty,  560 
Fibrinous  endometritis,  523 
Fibro-adenoma  of  parovarium,  419 
Fibroids,  menorrhagia  of,  radium  in,  529 

of  uterus,  307.     See  also  Myoma  of  uterus. 
Fibroma  molluscum  pendulum  of  vulva,  287 
of  Fallopian  tubes,  421 


Fibroma  of  ovary,  407 
ascites  from,  410 
of  pelvic  connective  tissue,  423,  424 
of  vulva,  286 

treatment,  287 
retroperitoneal,  424 
Fibromyoma  of  broad  ligament,  424 
of  Fallopian  tubes,  421 
of  infundibulopelvic  ligament,  425 
of  pelvic  connective  tissue,  423,  424 
of  round  ligament,  424 
of  uterus,  307.     See  also  Myoma  of  uterus. 
of  vagina,  304 
of  vulva,  286 
Fibromyxoma  cystosum  of  Fallopian  tubes, 

421 
Fibrosarcoma  of  ovary,  410 
Fissure  in  ano,  282 
treatment,  283 
of  bladder,  inferior,  449 
superior,  448 
Fistula,  enterovesical,  499 
in  ano,  281 

Elting's  operation  for,  282,  827 
Graves'  operation  for,  824-827 
operations  for,  824 
treatment,  282 
intracervical,  498 

operation  for,  659 
juxtacervical,  498 

operation  for,  659 
rectovaginal,  operation  for,  652,  653 
ureteral,  formation  of,  814 
urethrovaginal,  498 
uterovesical,  operation  for,  659 
vesical,  498 
diagnosis,  499 
operations  for,  653 
symptoms,  499 
treatment,  499 
vesicocervicovaginal,  498 

operation  for,  659 
vesico-uterine,  498 

operation  for,  659 
vesicovaginal,  498 

Braquehaye's  operation,  657 

Albarran's  modification,  657,  659 
operations  for,  653 
Sims'  operation,  653 
Flatus  vaginalis,  240 
Flexion  of  uterus,  lateral,  455 
Floating  kidney,  167 
Fluid  material,  absorption  of,  in  peritoneal 

cavity,  152, 153 
Flushes,  hot,  after  ovariectomy,  128 
Fold,  bloodless,  of  Treves,  172 


860 


INDEX 


Fold,  genitomesenteric,  of  Reid,  173 

parietocolic,  of  Jonnesco  and  Juvara,  172 
Follicles,  Graafian,  32,  37 

apparatus  as  organ  of  internal  secretion, 

46 
atresia  of,  40,  382 
cystic,  42 

during  pregnancy,  41 
manner  of  taking  place,  41 
obliterating,  42 
bursting  of,  internal  force  for,  37 
cyst  of,  381 

developing  and  ripening  of,  by  ovary,  32 
ripening  of,  33 
primordial,  33 

epithelial  layer  of,  33 
Foot  strain,  156 
Formalin  in  pyelitis,  277 
Freud's  theory  of  infantile  sexuaUty,  130-134 
Frying   pan   incision,    Kelly's,    for  nephrec- 
tomy, 804 
Functional  amenorrhea,  572 

incontinence   of  urine,   Kelly's   operation, 
combined    with    Graves'    anterior    col- 
poplasty,  615 
menorrhagia,  524 
Fungus  of  vagina,  238 
Furunculosis  of  external  genitalia,  96 
of  vulva,  225 

Gall-bladder,  operation  on,  during  pelvic 
operation,  149 
relation  of  genitaha  to,  147 
strawberry  mottling  of,  150 
GaU-stones,  148 

operation  for,  during  pelvic  operation,  149, 

150 
symptomless,  148 
treatment,  148-150 
Gamma  ray,  349 
Gangrene  of  bladder,  265 
Garruhtas  vaginae,  240 
Gartner's  duct,  439 
Gas,  expulsion  of,  from  vagina,  240 
Gelatin  solution  in  hemophiha,  107 
Genital    atrophy,    540.     See    also    Atrophy, 
genital. 
herpes,  96 
neurosis,  124 

of  imagination,  124 
of  overvaluation,  124 
treatment,  127 
psychoneuroses,  124 

treatment,  127 
spot,  100,  517 
tuberculosis,  215 


Genital  tuberculosis  as  cause  of  sterihty,  558 
Genitaha,  deficient  circulation  of,  ovarian  ex- 
tract in,  65 
eczema  of,  96 

effect  of  removal  of,  hypophysis  on,  76 
embryologic  development,  436 
external,    condition   of,    during   menstrua- 
tion, 20 
furunculosis  of,  96 
Genitomesenteric  fold  of  Reid,  173 
Germ-cells,  439 
Germinal  epithehum,  436 

of  ovary,  31 
Gerota's  capsule,  799 
Giantism  from  hyperfunction  of  hypophysis, 

77 
Gilliam's  operation  for  retroversion  of  uterus, 
467,  680 
Kelly's  modification,  685 
Mayos'  modification,  683 
Simpson's  modification,  681 
Gland,  carotid,  85 

h>"perplasia    of    endometrium,    cancer    of 

uterus  and,  differentiation,  368 
hypertrophy  of  endometrium,  249 
treatment,  251 
polj-poid,  of  endometrium,  250,  574 
radium  in,  527 
interstitial,  387 
Glands  of  internal  secretion,  dysfunction  of, 
45 
hjTDerfunctional  changes  in,  45 
hypofunctional  changes  in,  45 
relationship  of  gynecology  to,  44 
of  ovary  to,  46 
Glandular  ducts  of  ovary,  32 
Gl^nard's   disease,    158.     See   also    Entewp- 

tosis. 
Glycerin  and  ichthyol  in  chronic  pelvic  in- 
flammation, 212 
in  vaginitis,  238 
Glycogen  production  from  uterine  mucosa,  30 
Goffe's  operation  for  prolapse  of  uterus,  706 
Goiter  during  labor,  81 
during  menstruation,  80 
during  pregnancy,  80,  81 
exophthalmic,  81,  82 
at  menopause,  81 

question  of  marriage  and  reproduction 
in,  82 
Gonococcus,  177 

clinical  peciiharities,  177 
latent  power,  178 
Gonorrhea,  177,  181 
in  children,  179 
serum  treatment,  214 


INDEX 


861 


Gonorrhea,  vaccine  treatment,  214 
Gonorrheal  barthoUnitis,  184 
treatment,  185 
cystitis,  264,  274 
treatment,  269 
endocervicitis,  189 
chronic,  190 
treatment,  191 
endometritis,  192,  245 
endosalpingitis,  193 
hematosalpinx,  198 
hydrosalpinx,  196 

inflammation  of  Bartholin's  glands,  184 
treatment,  185 
of  endocervix,  189 
chronic,  190 
treatment,  191 
of  endometrimn,  192 
of  FaUopian  tubes,  192 
of  Skene's  glands,  183 
metritis,  251 
oophoritis,  253 
parametritis,  258 
peritonitis,  153 
pyosalpinx,  194 
salpingitis,    192.  See    also   Salpingitis, 

gonorrheal. 
tubo-ovaritis,  195 
urethritis,  181 

cystitis  and,  differentiation,  266 
stricture  of  urethra  as  result,  183 
symptoms,  182 
treatment,  183 
vulvitis,  179 

vulvovaginitis  in  children,  179 
treatment,  180 
Gonorrhoea  isthmica  nodosa,  198 
Graafian  follicle,  32,  37 

apparatus  as  organ  of  internal  secretion, 

46 
atresia  of,  40,  382 
cystic,  42 

during  pregnancy,  41 
manner  of  taking  place,  41 
obhterating,  42 
bursting  of,  internal  force  for,  37 
cyst  of,  381 
developing  and  ripening  of,   by  ovary, 

32 
ripening  of,  33 
Grafting,  omental,  after  myomectomy,  753 
Grape-mole  sarcoma  of  uterus,  329 
Graser's  operation  for  umbilical  hernia,  781 
Graves'  disease.     See  Exophthalmic  goiter. 
method  of  anterior  colpoplasty,  608 
of  making  artificial  vagina,  667 


Graves'   modification  of  Emmet's  operation 
for  laceration  of  perineum,  625 
for  rectocele,  625 
of  Olshausen's  operation  for  retroversion 
of  uterus,  678 
operation  for  anteflexion  of  uterus,  695 
for  closure  of  Douglas'  pouch  in  recto- 
cele, 643 
for  complete  laceration  of  perineum,  647 
for  cystocele,  608 
for  diastasis  of  rectus  muscles,  771 
for  enteroptosis,  167 
for  fistula  in  ano,  824-827 
for  postoperative  hernia,  782 
for  procidentia  of  uterus,  696 
for  umbilical  hernia,  775 
technic  in  application  of  radium  in  carci- 
noma of  cervix,  792 
Gynatresia,  535 
diagnosis,  539 
etiology,  536 
hematocolpos  in,  538 
hematometra  in,  538 
hematosalpinx  in,  538 

treatment,  539 
operations  for,  665 
symptoms,  537 
treatment,  539 
Gynecologic  diseases,  non-maUgnant,  radium 
in,  525-533 

after-care,  532 
details  of  treatment,  531 
dosage,  531 
selection  of  cases,  526 
operations,  lung  compUcations  after,  103 

Hair  on  face  in  middle  age,  23 
Hamamelis  in  menorrhagia  due  to   uterine 
fibroids,  325 

suppositories  in  hemorrhoids,  434 
Headache  during  menstruation,  20 
Hearing  during  menstrviation,  21 
Heart,  anemic,  114 

at  menopause,  114 

at  puberty,  113 

changes  in,  associated  with  uterine  fibroids, 
115 
from  hemorrhage  from  pelvic  disease,  114 

during  cohabitation,  113 

lesions  associated  with  uterine  myoma,  322 

mj'^oma  of,  115,  322 

relation  of  genitalia  to,  113 
Heat  in  acute  cystitis,  269 

treatment  of  carcinoma  of  cervix,  360 
Hegar's  operation  for  amputation  of  cervix, 

599,  604 


862 


INDEX 


Helmitol  in  cystitis,  269 
Hematocele  in  ectopic  pregnancy,  508,  511, 
512 

pelvic,  in  ectopic  pregnancy,  508 
Hematocolpos  in  gynatresia,  538 
Hematogenous  cystitis,  264 
Hematoma  in  ectopic  pregnancy,  508 

parametrial,  260 

parametritis  and,  differentiation,  259 
treatment,  261 
Hematometra,  444 

in  guinea-pigs,  production  of,  by  injection 
of  ovarian  extract,  65 

in  gynatresia,  538 
Hematosalpinx,  gonorrheal,  198 

in  ectopic  pregnancy,  508 

in  gynatresia,  538 
treatment,  539 
Hemophilia,  106 

familial  type,  106 

sporadic  type,  107 

treatment,  107 
Hemorrhage  from  pelvic  disease,  changes  in 
heart  muscle  from,  114 

in  carcinoma  of  cervix,  342 
of  rectum,  429 
of  uterus,  366,  367 

in  cervical  polyp,  333 

in  chorio-epithelioma  malignum,  376 

in  guinea-pigs,  production  of,  by  injection 
of  ovarian  extract,  65 

in  procidentia  of  uterus,  478 

in  tumors  of  bladder,  428 

intestinal,  at  menopause,  102 

of  eye,  puerperal  sepsis  as  cause,  99 

postpartum,  pituitrin  in,  79 

regeneration  of  blood  after,  103 

uterine.     See  Metrorrhagia. 
Hemorrhagic  metropathies,  vaporization  in, 

548 
Hemorrhoids,  432 

Allingham's  operation  for,  819 

bleeding,  during  menstruation,  102 

clamp  and  cautery  operation  for,  822 

diagnosis,  434 

dissection  and  ligation  for,  819 

etiology,  433 

external,  433 

internal,  433 

interno-external,  433 

operations  for,  819 

relation  of,  to  pregnancy  and  labor,  144 

thrombotic,  433 

treatment,  434 

Whitehead's  operation  for,  819 
Hermaphroditism,  71,  72,  451 


Hermaphroditism,  glandular,  72 
Hernia,  abdominal,  500 
operation  for,  775 
femoral,  Moschowitz's  operation  for,  787 
-   postoperative,  503 
diagnosis,  504 
Graves'  operation  for,  782 
transplantation  of  fascia  for,  782 

Bartlett's  method,  783 
treatment,  504 
shding,  432 
umbihcal,  502 

Graser's  operation  for,  781 
Graves'  operation  for,  775 
Mayos'  operation  for,  781 
Herpes,  genital,  96 
menstrual,  95 
sexualis,  95 
vesicae,  265 
Heterosexual  type  and  early  ovariectomy,  52 
Hitschmann  and  Adler  on  cyclic  changes  in 

uterine  mucosa,  24 
Hormones,  44 

Horn,  rudimentary,  of  uterus,  444 
Hot  flushes  after  ovariectomy,  128 

after  radium  treatment,  532 
House,   private,   examination  of  patient  in, 

834 
Hyaline  degeneration  of  uterine  myoma,  311 
Hydatid  mole,  374 

theca-lutein  cysts  associated  with,  387 
Hydatids  of  Morgagni,  421 
Hydrastis    in    monorrhagia    due    to    uterine 

fibroids,  325 
Hydrocele  muliebris,  292 
Hydrometra,  364 

due  to  closure  of  cervical  canal,  544 
Hydrops  tubse  profluens,  569 
Hydrosalpinx,  211 
congenital,  218 
gonorrheal,  196 
Hydrotherapy  in  enteroptosis,  164 
Hymen,  atresia  of,  536 
treatment,  539 
intra-uterine  closure,  536 
Hyperanteflexion  of  uterus,  455 
Hjrperfunction    of    hypophysis,    acromegaly 
from,  77 
giantism  from,  77 
of  ovary,  56 
of  suprarenals,  88 
Hjrperfunctional  changes  in  glands  of  internal 

secretion,  45 
Hyperleukocytosis  and  infection,  relation  be- 
tween, 107 
and  inflammation,  relation  between,  107 


INDEX 


863 


Hyperleukocytosis,  postoperative,  109 
Hypernephroma  as  cause  of  precocious  sexual 

development,  89 
Hyperpinealism,  90 
Hyperpituitarism,  77,  78 
Hyperplasia,  gland,  of  endometrium,  cancer 

of  uterus  and,  differentiation,  368 
Hypersecretion  of  ovary,  56 

uterine  bleeding  from,  57,  58 
Hyperthyroidism.     See  Exophthalmic  goiter. 
Hypertrophic  changes  in  uterus  before  and 

after  birth,  17 
Hypertrophy,  gland,  of  endometrium,  249 
treatment,  251 
radium  in,  527 
of  cervix  after  lacerated  cervix,  485 
of  clitoris,  295,  296 

of  suprarenal  gland  after  ovariectomy,  89 
pigment,   and  functions  of  pelvic  organs, 

rleation  between,  96 
polypoid  gland,  of  endometrimn,  250,  574 
Hypofunction  of  hj^Dophysis,  78 
dwarfism  from,  78 
of  ovary,  51 

infantilism  and,  relation  between,  55 
Hypofunctional  changes  in  glands  of  internal 

secretion,  45 
Hypophysis,  anatomic  structure  of,  73 
changes  in,  due  to  castration,  51,  52 
effect  of,  on  genitalia,  77 
in  pregnancy,  76 
diseases  of,  as  cause  of  sterility,  560 
effect  of  ovariectomy  on,  76 
extract  of,  value  of,  74,  78,  79 
hyperfunction  of,  acromegaly  from,  77 

giantism  from,  77 
hypofunction  of,  78 
dwarfism  from,  78 
relation  of  ovaries  to,  77 

to  genitalia,  73,  74 
removal  of,  effect  of,  74 
on  genital  organs,  76 
on  pregnancy,  76 
Hypoplasia  of  ovary,  infantiUsm  and,  rela- 
tion between,  55 
Hypoplastic  constitution,  55 
Hypospadias,  445 
Hypothyroidism,  82 
Hysterectomy,  713 
complete,  724 

steps  of  operation,  728 
for  uterine  myoma,  325 
in  hemophilia,  107 
neuroses  after,  128 
ovarian  extract  after,  64 
procidentia  after,  477 


Hysterectomy,  psychoneuroses  after,  128,  129 
supravaginal,  713 

vaginal  drainage  after,  723 
transplantation  of  ovarian  tissue  after,  766 
vaginal,  728 

for  carcinoma  of  cervix,  744-750 
Hysterostomatocleisis,  662 
Hysterotomy  in  uterine  insufficiency,  549 

IcHTHYOL  in  postoperative  phlebitis,  118 
in  pruritus  of  vulva,  236 
in  vaginitis,  238 
Ileopelvic  band,  173 
Imperforate  anus,  449 
Impregnation,  artificial,  in  sterility,  566 
Incision,  apron,  in  fistula  in  ano,  825 
Bardenheuer's,  768 
for  major  operations  on  kidney,  803 
for  nephrectomy,  803 
for   suspension   and   minor   operations   on 

kidney,  796 
Kelly's  frying  pan,  for  nephrectomy,  804 
Pfannenstiel's,  769 
transverse,  in  pelvic  operations,  768 
Incontinence    of    urine,    functional,    Kelly's 
operation,    combined   with   Graves' 
anterior  colpoplasty,  615 
operation  for,  614 
Infantile  myxedema,  82 
ovaries,  551 
sexuahty,  130 

masturbation  in,  132,  133 
onanism  in,  132,  133 
second  period  of,  133,  134 
thumb-sucking  as  manifestation,  131 
uterus,  553 
Infantihsm,  549,  550 

as  cause  of  sterility,  ovaries  in,  551 
tubes  in,  553 
uterus  in,  553 
etiology,  550 

hjrpofunction  of  ovary   and,   relation  be- 
tween, 55 
hypoplasia  of  ovary  and,  relation  between, 

55 
of  uterus,  480 
psychic,  137 
Infection  and  hyperleukocytosis,  relation  be- 
tween, 107 
and  leukocjrtosis,  relation  between,  107 
external,  resistance  of  peritoneum  to,  152 
of  endometrium,  244 
of  metrium,  251 
of  ovary,  252 
of  uterine  myoma,  320 
of  uterus,  251 


864 


INDEX 


Infection,  value  of  omentum  in  walling  off 

and  localization  of,  151 
Infectious  diseases,  acute,  acute  septic  vagi- 
nitis after,  157 
relation  of  genitalia  to,  157 
endometritis,  244 
treatment,  246 
metritis,  251 
oophoritis,  252 
chronic,  253 
etiology,  254 
symptoms,  254 
treatment,  255 
Inflammation  and  hj^jerleukocytosis,  relation 
between,  107 
gonorrheal,  of  Barthohn's  glands,  184 
treatment,  185 
of  endocervix,  189 
of  endometrimn,  192 
of  Fallopian  tubes,  192  . 
of  Skene's  glands,  183 
of  urethra,  181 
of  bladder,  262 

in  old  women,  272 
of  colon,  277 
of  endometriima,  242 
of  large  intestine,  277 
of  ovary,  252 
of  parametrium,  255 
of    pelvic    cellular    tissue,    256.     See    also 

Paravietritis. 
of  pelvis  of  kidnej^,  273 
of  peritonemn,  pain  from,  578 
of  uterus,  251 
gonorrheal,  251 
infectious,  251 
tubercular,  251 
of  vagina,  236 
of  vulva,  224  ■ 

pelvic,  chronic,  as  result  of  gonorrheal  sal- 
pingitis, 202,  209.       See  also  Pelvic 
inflam77iation,  chronic. 
relation  of,  to  retroversion  and  retro- 
flexion of  uterus,  283 
menorrhagia  of,  radium  in,  530 
Inflammatory  processes,  general,  224 
stricture  of  rectum,  283 
treatment,  285 
Influenza    and    genitalia,    relation    between, 

157,  158 
Infundibulopelvic      ligament,      fibromyoma, 

425 
Inguinal  regions,  dissection  of,  for  carcinoma 

of  vulva,  Bassett's  method,     584,  585 
Injuries  due  to  childbirth,  485 
Insanity,  influence  of  menstruation  on,  124 


Internal  secretion,  effect  of  nervous  system 
upon,  44,  45 
glands  of,  dysfunction  of,  45 
hyperfunctional  changes  in,  45 
hypofunctional  changes  in,  45 
relationship  of  gynecology  to,  44 
of  ovary  to,  46 
secretory  function  of  suprarenal  system,  85 
Interposition  operation  in  prolapse  and  proci- 
dentia of  uterus,  479,  699 
Interstitial  cells  as  producers  of  internal  se- 
cretion, 49 
existence  of,  48 
growth  of,  50,  51 
origin  of,  48,  49 
endometritis,  radium  in,  528 
gland,  42,  387 

and  corpus  luteum,  reciprocal  relation- 
ship between,  50 
pregnancy,  506 

symptoms  and  course,  513 
Intestinal  bands,  172 
attic  adhesions,  173 
bloodless  fold  of  Treves,  172 
diagnosis,  176 

genitomesenteric  fold  of  Reid,  173 
ileopelvic,  173 
Jackson's  membrane,  172 
Lane's  kink,  173 
origin,  173 
parietocohc  fold  of  Jonnesco  and  Juvara, 

172 
points  of  formation,  175 
s5T2iptoms,  175 
treatment,  176 
diverticula,  277.      See  also  Diverticula,  in- 
testinal. 
hemorrhage  at  menopause,  102 
stasis,  158,  163 
Intestine,  large,  inflammation  of,  277 

relation  of  genitalia  to,  142,  144 
Intra-abdominal  bands,  172.    See  also  Intes- 
tinal bands. 
Intracervical  fistula,  498 

operation  for,  659 
Intraligamentary  fibroid,  310 
Intra-uterine  closure  of  hymen,  536 
Inversion  of  uterus,  458,  482 
complete,  482 

conservative  operation,  710 
diagnosis,  483 
incomplete,  482 
Ktistner's  operation,  710 
myoma  and,  differentiation,  483 
onkogenetic,  482 
Spinelli's  operation,  711 


INDEX 


865 


Inversion  of  uterus,  symptoms,  483 

treatment,  483 
Invertent  carcinoma  of  cervix,  336,  338 
lodin  in  carcinoma  of  cervix,  362 

in  cervicitis,  242 

in  chronic  pelvic  inflammation,  212 

in  condyloma  acuminata  of  vulva,  228 

in  endocervicitis,  242 

in    gonorrheal    inflammation    of    Skene's 
glands,  184 

in  membranous  dysmenorrhea,  523 

in  pruritus  of  vulva,  236 

in  vaginitis,  238 
Ischiorectal  abscess,  280 
Ischuria  paradoxa,  142 

Jackson's  membrane,  172 
Joints,  relation  of  genitalia  to,  156 
Jonnesco  and  Juvara,  parietocolic  fold  of,  172 
Jux-tacervical  fistula,  498 
operation  for,  659 

Kaolix  poultices  in  postoperative  phlebitis, 

118 
Katz's  theor}'  of  cause  of  ectopic  pregnancy, 

507 
Kelly's  frying  pan  incision  for  nephrectomy, 
804 
method  of  suprapubic  c3^stotomy,  815 

of  vaginal  cystostomy,  816 
operation   for   functional   incontinence   of 
urine,  combined  with  Graves'  anterior 
colpoplasty,  615 
for  retroversion  of  uterus,  685 
in  uterine  insufficiency,  549 
technic  of  suspension  of  kidney,  800 
Kidney,  abscess  of,  273 
extirpation  of,  803 

for  injury  of  ureter,  813 
floating,  167 

mode  of  entrance  of  bacteria  to,  273 
movable,  167 

and  appendicitis,  association,  170 

and  movable  cecum,  influence  between, 

169 
diagnosis  of,  170 
etiology  of,  167 

pyelography  as  aid  in  diagnosis,  171 
symptoms,  169 
treatment,  171 
■     operations  on,  796 

major,  incision  for,  803 
minor,  796 

incision  for,  796 
pelvis  of,  inflammation,  273 
removal  of,  803-809 
55 


Kidney,  suppurating,  273 
suspension  of,  796 

Kelly's  technic,  800 
tumors  of,   ovarian  tumors  and,  differen- 
tiation, 415 
Kink,  Lane's,  173 
Knee-chest  position,  834 
Kram-osis  of  vulva,  232 
radium  in,  531 
treatment,  233 
Kristeller,  565 

Kronig's  modification  of  Sampson's  method  of 
ureterovesical  transplantation,  813 
operation  in  carcinoma  of  cervix,  361 
Krukenberg's  tumor,  407 
Klistner's  operation  for  inversion  of  uterus, 
710 

Labia  majora,  atrophy,  542 

minora,  atrophy,  542 
Labor,  appendicitis  during,  147 

goiter  during,  80 
Laceration  of  cervix,  485 

carcinoma  and,  differentiation,  486 
diagnosis,  486 

Emmet's  operation,  487,  593 
hypertrophy  after,  485 
metrorrhagia  in,  516 
operative  treatment,  593 
symptoms,  486 
treatment,  487 
of  perineum,  490 

Clark's  operation  for,  633 
complete,  Clark's  operation  for,  636 
Emmet's  operation.  Graves'  modifica- 
tion, 647 
Graves'  operation,  647 
operation  for,  647 
Warren's  operation,  652 
diagnosis,  497 
during  labor,  494 
effect  of,  493-495 
Emmet's  operation,  497 

Grave's  modification,  625 
Studdiford's  operation,  638 
symptoms,  496 
treatment,  497 
Lactation,  condition  of  uterus  during,  543 

sterility,  560 
Lactation-atrophy,  543 

of  ovaries,  56 
Lane's  kink,  173 

operation  for  enteroptosis,  165 
Langhans'  cells,  372 

layer,  372 
Layer,  compact,  of  uterine  mucosa,  26 


866 


INDEX 


Layer,  epithelial,  of  primordial  follicle,  33 

Langhans',  372 

medullary,  of  ovary,  32 

parenchymatous,  of  ovary,  32 

spongy,  of  uterine  mucosa,  26 
Lead-and-opium  lotion  in  postoperative  phle- 
bitis, 118 
Leg,  milk-,  116,  257 
Legs,  pain  in,  581 

varicose  veins  of,  119 

Mayos'  operation  for,  729 
operations  for,  728 
Leiomyoma  of  uterus,  307.     See  also  Myoma 

of  uterus. 
Length  of  stay  in  bed  in  abdominal  opera- 
tions, 842 
Leukocytosis  after  blood  extravasation,   109 

and  infection,  relation  between,  107 

in  absorption  of  products  of  degeneration 
in  necrotic  tissue,  109 

postoperative,  109 
Leukoplakia  of  vulva,  234 
Leukorrhea,  568 

following  radium  treatment,  532 

from  endocervix,  191 

in  carcinoma  of  cervix,  342,  570 

following  radium  treatment,  359,  360 

in  cervical  polj^ps,  333 

in  chronic  endometritis,  192 
gonorrheal  endocervicitis,  191 
pelvic  inflammation,  209 

in  endocervicitis  and  cervicitis,  242 

in  erosion  of  cervix,  241 

in  gland  hypertrophy  of  endometrium,  251 

in  retroversion  of  uterus,  464 

in  stenosis  of  vagina,  537 

in  tubercular  endometritis,  220 

in  vaginitis,  237,  238 
Levator  ani  muscle,  490 
Leydig,  cells  of,  48 
Ligament,  appendiculo-ovarian,  145,  173 

broad,  fibromyoma  of,  424 
varicose  veins  in,  119 

infundibulopelvic,  fibroma  of,  425 

round,  adenomyoma  of,  423 
fibromyoma  of,  424 
tumors  of,  422 
treatment,  423 
Ligation  of  proximal  end  of  ureter,  813 
Lipoma  of  pelvic  connective  tissue,  425 

of  vulva,  287 

retroperitoneal,  425 
Liquor  folHculi,  34 
Loins,  pain  in,  580 
Lumbar  pain,  580 

trigonum,  superior,  798 


Lung  complications  after  gynecologic  opera- 
tions, 103 
tuberculosis  of,  influence  of  menstruation 
on,  104 
Lupus  of  vulva,  220 
Lutein  cells,  39 

Lymphangioma  of  Fallopian  tubes,  421 
Lymph-glands,  infection  of,  in  carcinoma  of 
cervix,  346 
of  peritoneum,  151 
Lymphosarcoma  of  uterus,  330 
Ljoich's  thyrotome  in  stricture  of  rectum,  285 

Malaria  and  metrorrhagia,  relation  between, 

158 
Malignant  chorio-epithelioma,  370 

degeneration  of  uterine  fibroids,  317,  329, 
331 
Malposition  of  uterus,  453 
as  cause  of  sterility,  558 

treatment,  561 
backache  in,  579 
dysmenorrhea  and,  relation,  517 
operations  for,  678 
Malthusian  doctrine,  560 
Mammary  extract  in  menorrhagia,  94 
in  uterine  bleeding,  94 
glands.     See  Breasts. 
Mammin  in  menorrhagia,  94 

in  uterine  bleeding,  94 
Marchant's    operation  for    rectal    prolapse, 

817 
Mascuhne  type,  reversion  to,  during  meno- 
pause, 23,  134 
Masturbation,  132,  134-138 

early,  influence  of,  on  character,  136 

excessive,  in  child,  135 

in  matured  women,  137 

second  stage  of  childhood,  influence  of,  on 

character,  132 
uninhibited,  135 
Maternal  placenta,  47 
Maturity,  ovariectomy  after,  53 

before,  51 
Mayos'  operation  for  prolapse  and  prociden- 
tia of  uterus,  709 
for  retroversion  of  uterus,  683 
for  umbilical  hernia,  781 
for  varicose  veins,  829 
Medullary  layer  of  ovary,  32 
Melanosarcoma  of  uterus,  330 
Membrana  granulosa,  34 
Membrane,  Jackson's,  172 
Membranous  dysmenorrhea,  522.        See  also 

Dysmenorrhea,  membranous. 
Menopause,  age  occurring,  19 


INDEX 


867 


Menopause,  atrophy  of  ovaries  as  cause  of 

changes  during,  23 
constipation  at,  102 
constitutional  changes  during,  22 
diarrhea  at,  102 
digestive  disturbances  at,  102 
disturbances  of,  placental  extracts  in,  65 
eczema  of,  96 
exophthalmic  goiter  at,  81 
heart  at,  114 
influence  of  climate  on,  19 

on  thyroid,  81 
intestinal  hemorrhage  at,  102 
loss  of  ovarian  secretion  as  cause  of  changes 

during,  23 

menorrhagia  at,  causes,  22  

nasal  catarrh  at,  100 

nervous  symptoms  of,  128,  129 

nose  during,  99 

obesity  during,  23 

physical  changes  during,  22 

psychic  disturbances  during,  22 

psychoneuroses  of,  129 

reversion    to    masculine   type  during,  23, 

134 
sexual  impulse  just  before,  23 
vasomotor  disturbances  of,  114,  129 
Menorrhagia,  572 

appearance  of  blood  after,  109 
at  menopause,  causes,  22 
causes,  574 
from  uterine  fibroids,  322 

treatment,  325 
functional,  524 

in  gland  hypertrophy  of  endometrium,  251 
in  retroversion  of  uterus,  464 
mammary  extract  in,  94 
neuroses  from,  123 
of  fibroids,  radium  in,  529 
of  pelvic  inflammation,  radium  in,  530 
of  youth,  524 

radium  in,  528 
thyreopriva,  80 
Menstrual  blood,  amount  lost,  20 

non-coagulability  of,  20,  105 
changes  in  skin,  95 
exanthemata,  95 

exfohation  of  uterine  mucosa,  522 
herpes,  95 
salivation,  100 
Menstruating  endometrium,  physiologic  anat- 
omy, 24 
Menstruation,  abnormaUties  of,  571 
age  occurring,  18 
amount  of  blood  lost  during,  20 
and  acne,  relation  between,  96 


Menstruation  and  chronic  appendicitis,  rela- 
tion between,  146 
and  erysipelas,  relation  between,  96 
and  ovulation,  time  relation  between,  58, 

59 
bleeding  hemorrhoids  at,  102 
blood  during,  105 
cessation  of,  19,  22 
condition  of  breasts  during,  20 

of  circulatory  system  in,  21 

of  digestive  system  during,  20 

of  external  genitals  during,  20 

of  eyes  during,  21 

of  Fallopian  tubes  during,  20 

of  nervous  system  during,  20 

of  ovaries  during,  20 

of  skin  during,  21 

of  uterus  during,  20 
congestion  of  pelvic  blood-vessels  during, 

20 
diarrhea  during,  102 

disturbances  of,  in  chronic  pelvic  inflam- 
mation, 210  , 

in  ovarian  tumors,  414 

in  retroversion  of  uterus,  464 

of  mouth  during,  100 

of  stomach  and,  relationship,  100,  101 
duration  of,  19,  20 
effect  of  climate  on  occurrence  of,  18,  19 

of  social  conditions  on  occurrence  of,  19 
enlargement  of  breast  during,  18 

of  thyroid  gland  in,  20 
epistaxis  during,  21 
establishment  of,  18 

factors  which  influence,  18 
goiter  during,  80 
headache  during,  20 
hearing  during,  21 
herpes,  95 
increased  activity  of  parotid  glands  during, 

100 
influence  of  disturbed  psychic  states  on,  123 

of  nervous  shock  on,  123 

of  psychic  excitement  on,  21 

on  insanity,  124 

on  mental  diseases,  123 

on  nervous  diseases,  120,  123 

on  tuberculosis  of  lungs,  104 
irregularity  of,  19 

neuroses  from,  122 
molimina  of,  571 

myoma  of  uterus  and,  relation,  323 
non-coagulability  of  blood  of,  105 
nose  during,  99 
nose-bleed  during,  21 
Ott's  curve,  121 


INDEX 


Menstruation,  pains  of,   21,   580.     See  also 
Dysmenorrhea. 

pelvic  discomfort  during,  20 

performing  pelvic  operations  during,  22 

phsyiology  of,  18 

precocious,  21 
in  infants,  18 

sense  of  well-being  during,  20 

sexual  impulse  during,  21 

suicide  during,  123 

tubal,  30 

vasomotor  disturbances  during,  21 

vicarious,  21 

skin  lesion  from,  96 

vocal  cords  during,  21,  104 

voice  during,  21,  104 

wave  theory,  120 
Mental  diseases,  influence  of  menstruation  on, 

123 
Mercury,  bichlorid  of,  in  pyelitis,  277 
Mesothorium  in  carcinoma  of  cervix,  348 
Metritis,  251 

gonorrheal,  251 

infectious,  251 

tubercular,  251 
Metropathies,  hemorrhagic,  vaporization  in, 
548 

radium  in,  technic,  795 
Metrorrhagia,  575 

and  malaria,  relation  between,  158 

appearance  of  blood  after,  109 

from  arteriosclerosis,  115,  116 

from  hypersecretion  of  ovary,  57,  58 

from  uterine  fibroids,  322 
treatment,  325 

in  carcinoma  of  cervix,  576 
of  uterus,  576 

in  cervical  poljqjs,  576 

in  chorio-epithelioma  malignum,  575 

in  extra-uterine  pregnancy,  508,  509,  511, 
576 

in  lacerations  of  cervix,  576 

in  sarcoma  of  uterus,  331 

mammary  extract  in,  94 
Micturition,  painful,  581 
Mid-line  abdominal  ptosis,  160 
Milk-leg,  116,  257 
Mole,  hydatid,  374 

theca-lutein  cysts  associated  with,  387 

tubal,  508,  511 
Molimina  of  menstruation,  571 
Morgagni,  hydatids  of,  421 
Morphin  in  carcinoma  of  cervix,  361 

suppositories  in  hemorrhoids,  434 
Moschowitz's  operation  for  femoral  hernia, 

787 


Moschowitz's  operation  for  rectal  prolapse, 

817,  818 
Mouth,    disturbances   of,    during   menstrua- 
tion, 100 
Movable    cecum    and    movable   kidney,    in- 
fluence between,  169 
kidney,  167 

and  appendicitis,  association,  170 

and  movable  cecum,  influence  between, 
169 

diagnosis,  170 

etiology,  167 

pyelography  as  aid  in  diagnosis,  171 

symptoms,  169 

treatment,  171 
Mucosa,  uterine,  compact  layer,  26 

cyclic  changes  in,  24 

glycogen  production  from,  30 

menstrual  flow  and,  28 

postmen  strual  involution  of,  28 

premenstrual  congestion  of,  24 

spongy  layer,  26 
Mucous  polyps  of  Fallopian  tubes,  421 

of  vestibule,  293 
Miifler's  ducts,  436,  441 

failure  of  union,  results  of,  441 
Muscles,  recti,  diastasis  of,  500 
operation  for,  771-774 
treatment,  501 
Myoma,  ball,  of  uterus,  310 
cervical,  310,  311 
heart,  115,  322 
of  uterus,  307 

adenocarcinomatous  degeneration,  319 

and  menstruation,  relation,  323 

and  pregnancy,  relation,  322 

and  thyroid,  relation  between,  81 

angiomatous  degeneration,  315 

as  cause  of  sterility,  559 

atrophy,  316,  317 

ball,  310 

calcification,  316 

carcinoma  and,  differentiation,  323 
associated  with,  366,  367  • 

carcinomatous  degeneration,  319 

centrifugal,  308 

centripetal,  308 

changes  in,  due  to  passive  congestion,  311 

classification,  308 

cystic  degeneration,  314 

degeneration,  311 

diagnosis,  323 

edematous  degeneration,  311 

etiology,  307 

fatty  degeneration,  315 

frequency,  320 


INDEX 


869 


Myoma  of   uterus,   heart  lesions  associated 
with,  115,  322  . 
hyaline  degeneration,  311 
hysterectomy  for,  325 
in  well-to-do,  342 
infection,  320 
interstitial,  309 
intraligamentary,  310 
intramural,  309 

inversion  and,  differentiation,  483 
malignant  degeneration,  317,  329,  331 
menorrhagia  from,  322 

treatment,  325 
menstruation  and,  relation,  323 
metrorrhagia  from,  322 
myomectomy  for,  325 
myxomatoid  degeneration,  314 
myxomatous  degeneration,  313 
necrosis  of,  315 
operations  for,  750 
pain  from,  680 
pregnancy  and,  differentiation,  324 

relation,  322 
red  degeneration,  314,  316 
regressive  changes,  316 
sarcomatous  degeneration,  317,  329,  331 
submucous,  310 
subserous,  309 

supravaginal  hysterectomy  for,  325 
symptoms,  321 
thrombotic  degeneration,  314 
treatment,  324 
uterine  hemorrhage  from,  322 

treatment,  325 
vasomotor  symptoms,  115 
of  vagina,  304 
Myomectomy,  abdominal,  750,  751 
for  uterine  myoma,  325 
omental  grafting  after,  753 
operations,  750 
vaginal,  756 
Myomherz,  81 
Myosarcoma  of  Fallopian  tubes,  423 

of  uterus,  329 
Myxedema,  82 
congenital,  82 
infantile,  82 
postoperative,  82 
Myxoma  of  vulva,  292 
Myxomatoid  degeneration  of  uterine  myoma, 

314 
Myxomatous  degeneration  of  uterine  myoma, 
313 

Nabothian  cysts,  191 

Nasal  catarrh  at  menopause,  100 


Nasal  dysmenorrhea,  517 

mucous  membrane,   cocainizing,   influence. 

of,  on  dysmenorrhea,  100 
treatment  of  dysmenorrhea,  519 
Necrosis  of  uterine  fibroids,  315 
Necrospermia,  556 
Necrotic   tissue,    absorption   of   products   of 

degeneration  in,  leukocytosis  in,  109 
Nephrectomy,  803-809 
for  injury  of  ureter,  813 
in  pyelitis,  277 

in  tuberculosis  of  bladder,  271 
incision  for,  803 

Kelly's  frying  pan  incision  for,  804 
Nephroptosis,    167.      See  also  Movable  kid- 
ney. 
Nephrotomy  in  pyelitis,  277 
Nerves  of  peritoneum,  151 
Nervous  diseases,  influence  of  menstruation 
on,  123 
symptoms  of  menopause,  128,  129 
system,  condition  of,  during  menstruation, 
20 
influence  of  menstruation  on,  120 

on  internal  secretion,  44,  45 
relation  of  genitalia  to,  120 
Neuralgia,  ovarian,  127,  255,  578 
Neuroma  of  vulva,  292 

Neurosis    after    hysterectomy    and    ovariec- 
tomy, 128 
as  result  of  masturbation,  136 

of  menstrual  irregularities,  122 
from  amenorrhea,  123 
from  dysmenorrhea,  122 
from  menorrhagia,  123 
genital,  124 

of  imagination,  124 
of  overvaluation,  124 
treatment,  127 
New  growths.     See  Tumors. 
Newborn,  atresia  of  hymen  in,  536 

sexual  impulse  in,  130 
Nodular  tubercular  peritonitis,  221 
Non-malignant    gynecologic  diseases,  radium 
in,  525-533 
after-care,  532 
details  of  treatment,  531 
dosage,  531 
selection  of  cases,  526 
Nose  during  menopause,  99 
during  menstruation,  99 
relation  of  genitalia  to,  99 
vicarious  menstruation  from,  21 
Nose-bleed  during  menstruation,  21 
Nuck,  canal  of,  cyst  of,  292 


870 


INDEX 


Obesity  as  cause  of  sterility,  560 

.    during  menopause,  23 

Oil  of  copaiba  in  gonococcal  cystitis,  269 

of  sandalwood  in  gonococcal  cystitis,  269 
Ointment,  Crede's,  in  varicose  ulcer,  830 

scarlet,  in  varicose  ulcer,  830 
Oligomenorrhea,     functional,     ovarian    defi- 
ciency and,  56 
extract  in,  65 
of  youth,  524 
Olshausen's  operation  for  prolapse  of  uterus, 
474 
for  retroversion  of  uterus,  468 
Graves'  modification,  678 
Omental  grafting,  753 
Omentum,  absorbing  power,  152 

capacity  of,  to  slip  into  defects  of  abdom- 
inal wall,  152 
grafting  of,  after  myomectomy,  753 
physiology  of,  150 
protective  power,  151 
.     relation  of  genitaUa  to,  150 
use  of,  in  plastic  operations,  152 
value  of,  in  walhng  off  and  localization  of 
infection,  151 
Onanism,  131,  132.     See  also  Masturbation. 
Onkogenetic  inversion  of  uterus,  482 
Oophorectomy.     See  Ovariectomy. 
Oophoritis,  252 
gonorrheal,  253 
infectious,  252 
chronic,  253 
etiology,  254 
symptoms,  254 
treatment,  255 
interstitial,  252,  253 
etiology,  254 
symptoms,  254 
treatment,  255 
tubercular,  253 
tubo-,  chronic,  199,  200 
Operations,  abdominal,  length  of  stay  in  bed, 
842 
preparation  for,  835 
support  after,  842 
suture  materials,  838 
technical  detail,  836 
treatment  after,  840 
on  abdominal  wall,  768 
on  bladder,  815 
on  cervix,  591 
on  Fallopian  tubes,  757 
on  kidney,  796 

major,  incision  for,  803 
minor,  796 

incision  for,  796 


Operations  on  ovaries,  764 
on  rectum,  817 
on  ureters,  810 
on  vagina,  608 
on  vulva,  582 

plastic,  after-care  of,  845  ' 

care  of  stitches,  846 
coaptation  of  wound  edges,  845 
denudation  in,  844 
preparation  for,  842 
stitch  abscess  in,  treatment,  847 
suture  material,  844 
technic  of,  842 
technical  details,  843 
Operative  gynecology,  582 
Osteoma  of  vulva,  292 

Osteomalacia  and  ovaries,  relation  between, 
156 
and  parathyroids,  relation  between,  84 
Ott,  curve  of,  121 
Ova,  439 

Ovarian  dysmenorrhea,  517 
extract  after  hysterectomy,  -65 
dosage,  66 
form  used,  66 
fresh,  importance  of,  66 
in  absence  of  ovarian  secretion,  65 
in  amenorrhea  of  youth,  524 
in  deficient  circulation  of  genitalia,  65 
in  dysmenorrhea,  519 
in    functional    amenorrhea    and    oligo- 
menorrhea, 65 
in  kraurosis  of  vulva,  233 
in  pruritus  of  vulva,  236 
in  sclerosis  and  atrophy  of  ovary,  255 
in  sterility,  65,  566 
in  vasomotor  changes  after  ovariectomy, 

128 
influence    of,    on   time    coagulability   of 

blood,  58 
production  of  hematometra  in  guinea- 
pigs  by  injection  of,  65 
of  hemorrhage  in  guinea-pigs  by  injec- 
tion of,  65 
value  of,  64 
facies,  412 

neurahga,  127,  255,  578 
pain,  577 
secretion,  46 

absence  of,  ovarian  extract  in,  65 
loss  of,  as  cause  of  changes  during  meno- 
pause, 23 
tissue,  transplantation  of,  60,  765 
after  hysterectomy,  63,  766 
in  functional   amenorrheas   of  young 
women,  64 


INDEX 


871 


Ovarian  tissue,  transplantation  of,  in  sterility, 

62,  565 
Ovariectomy,  accumulation  of  fat  after,  52, 

53,  54 
after  maturity,  53,  134 
as  cause  of  amenorrhea,  571 
before  maturity,  51 

puberty  in  women,  53 
changes  in  hypophysis  due  to,  51,  52 
early  and  late,  differences  in,  53,  54 

heterosexual  type  in,  52 
effect  of,  46 

on  hypophysis,  76 
genital  atrophy  due  to,  543 
hot  flushes  after,  128 
hypertrophy  of  suprarenal  gland  after,  89 
neuroses  after,  128 
psychoneuroses  after,  128,  129 
transplantation  of  ovarian  tissue  after,  63 
vasomotor  disturbances  after,  55,  128 
voice  after,  52 
Ovarin,  46 

Ovaritis,  252.     See  also  Oophoritis. 
Ovary,  absence  of,  445 
absence  of  vagina  and,  55 
accessory,  445 
albuginea  of,  32 

and  breasts,  relation  between,  94 
and  osteomalacia,  relation  between,  156 
atrophy  of,  55,  542 

as  cause  of  changes  during  menopause,  23 

pathologic,  56 
blood-cysts  of,  386 
carcinoma  of,  398.     See  also  Carcinoma  of 

ovary. 
colloid  carcinoma,  405,  406,  407 
condition  of,  during  menstruation,  20 
cystadenoma  of,  387 

origin,  396 

pseudomucinous,  389 
origin  of,  397 
treatment,  391 

serous,  393 
origin  of,  396 
cystic  carcinoma,  398 

degeneration,  383 

as  cause  of  sterility,  558 
cystoma  of,  387 

cysts  of,  254,  381.     See  also  Cijsts  of  ovary. 
defects  of,  developmental,  445 
degeneration  of,  254 

cystic,  254 
dermoid  cysts  of,  401,  408,  409 
malignant  changes,  403 
parthenogenesis,  405 
descent  of,  440 


Ovary,  developing  and  ripening   of  follicles 

by.  32 
development  of,  18 
embryologic  development,  439 
endothelioma  of,  411 
fibroma  of,  407 

ascites  from,  410 
fibrosarcoma  of,  410 
function  of,  essential,  32 
functional  anatomy,  31 
germinal  epithelium  of,  31 
glandular  ducts  of,  32 
hyperfunction  of,  56 
hypersecretion  of,  56 

uterine  bleeding  from,  57,  58 
hypof unction  of,  51 

infantilism  and,  relation  between,  55 
hypoplasia    of,    infantilism    and,    relation 

between,  55 
in  infantiUsm  as  cause  of  sterility,  551 
infantile,  551,  552 
infections,  252 
inflammations,  252 
lactation-atrophy  of,  56 
medullary  layer  of,  32 
operations  on,  764 
parenchymatous  layer  of,  32 
perithelioma  of,  411 
physiologic  anatomy,  31 
pseudomucinous  cystadenoma  of,  389 
origin,  397 
treatment,  391 
relation  of,  to  glands  of  internal  secretion, 
46 

to  hypophysis,  77 

to  thyroid,  80 
resection  of,  764 
sarcoma  of,  410 

metastasis,  411 
secretion  of,  46 
serous  cystadenoma  of,  393 

origin,  396 
small  cystic  degeneration,  254 
stigma  on,  37 
struma,  404 
teratoma  of,  404 

parthenogenesis,  405 
transplantation  of,  60,  765 

after  hysterectomy,  766 

in  sterility,  565 
tuberculosis  of,  220,  253 
tumors  of,  381 

ascites  associated  with,  412 

diagnosis,  415 

exciting  cause  of  formation,  397 

facial  expression,  412 


872 


INDEX 


Ovary,  tumors  of,  menstrual  function  in,  414 

non-proliferating,  381 

ovigenous,  401 

ovulogenous,  401 

parenchymatous,  387 

pregnancy  complicating,  414 

pressure  symptoms,  412 

prognosis,  417 

proliferating,  387 

removal  of  both  ovaries,  417 

stromatogenous,  407 

symptoms,  412 

torsion,  413 

treatment,  416 

tumors   of  kidney   and,    differentiation, 
415 

m-eter  sjTxiptoms,  412 
■Ovigenous  tumors  of  ovary,  401 
Ovitestes,  72,  451 

Ovulation  and  menstruation,  time  relation  be- 
tween, 58,  59 
Ovulogenous  tumors  of  ovary,  401 
Ovum  and  spermatozoon,  place  of  union,  24 

Facet's  disease  of  vulva,  234 

Pain  from  inflammation  of  peritonevmi,  578 

from  pelvic  pressure,  578 

from  uterine  fibroids,  580 

in  carcinoma  of  cervix,  343 

in  coccyx,  580 

in  coitus,  138,  140 

in  dysmenorrhea,  518,  519 

in  ectopic  pregnancy,  510,  511,  512 

in  legs,  581 

in  loins,  580 

in  retroversion  of  uterus,  463 

in  rupture  of  tubal  pregnancy,  577 

in  side,  579 

intermenstrual,  21 

lumbar,  580 

of  menstruation,  580.     See  also  Dysmenor- 
rhea. 

of  micturition,  581 

on  defecation,  581 

ovarian,  577 

pelvic,  576 
Palpation  of  abdomen,  831 
Papillary  angioma  of  vestibule,  293 

excrescences  of  vulva,  227 
Papilloma  of  bladder,  426 
treatment,  428 

of  Fallopian  tubes,  421 
Paracolpitis,  240 
Paracystic  cellular  tissue,  256 
Paracystitis,  265 
.  Paraffin,  liquid,  in  enteroptosis,  164 


Parametrial  cellular  tissue,  256 
hematoma,  260 

parametritis  and,  differentiation,  259 
treatment,  261 
infiltration    in    chorio-epithelioma    malig- 
num,  380 
Parametritis,  255,  256 

as  complication  of  pelvic  operations,  257 

atrophicans,  259 

cancer  of  cervix  and,  differentiation,  259 

chronic,  258,  259 

cystitis  from,  264 

diagnosis,  259 

differential,  259 
etiology,  257,  258 
gonorrheal,  258 
parametrial  hematoma  and,  differentiation, 

259 
posterior,  144,  259 
postoperative,  257 
symptoms,  258 
treatment,  259 
Parametrium,  hematoma  of,  260 

inflammation  of,  255 
Paraproctal  ceUular  tissue,  256 
Parasites,  vaginal,  238 
Parathyroid  extract  in  tetany,  83 
Parathyroids    and    eclampsia,    relation    be- 
tween, 84 
and  osteomalacia,  relation  between,  84 
relation  of,  to  genitalia,  83 
removal  of,  effect  of,  83 
Paravaginitis,  240 
Parenchymatous  layer  of  ovary,  32 
Farenteric  digestion,  110 
Parietocolic   fold    of   Jonnesco   and    Juvara, 

172 
Paroophoron,  439 
Parotid    glands,    increased    activity,    during 

menstruation,  100 
Parovarium,  418,  439 
adenomyoma  of,  419 
adenosarcoma  of,  419 
carcinoma  of,  419 
cystadenoma  of,  419 
cysts  of,  418 

treatment,  419 
dermoid  cysts,  419 
fibro-adenoma  of,  419 
tumors  of,  419 
Patient,  examination  of,  831. 

in  private  house,  834 
Pedicle,  upper,  585,  586 

Pelvic  adhesions  after  gonorrheal  salpin- 
gitis, 202.  See  also  Pelvic  inflammation, 
chronic. 


INDEX 


873 


Pelvic    blood-vessels,  congestion    of,   during 
menstruation,  20 
cellular  tissue,  anatomy,  255 

inflammations,    256.     See   also   Para- 
metritis. 
paracystic,  256 
parametrial,  256 
paraproctal,  256 
cellulitis,  255 

after  operations  on  bladder,  260 
in  lateral  wall  of  abdomen,  260 
connective  tissue,  dermoid  cysts,  425 
treatment,  426 
fibroma  of,  423,  424 
fibromyoma  of,  423,  424 
lipoma  of,  425 
sarcoma  of,  425 
tmnors  of,  423 
symptoms,  424 
treatment,  426 
discomfort  during  menstruation,  20 
hematocele  in  ectopic  pregnancy,  508 
inflammation,  chronic,  as  result  of  gonor- 
rheal salpingitis,  202,  209 
disturbances  of  menstruation  in, 

210 
symptoms,  209 
treatment,  212 
menorrhagia  of,  radium  in,  530 
.  relation  of,  to  retroversion  and  retro- 
flexion of  uterus,  202 
operations,  Bardenheuer's  incision,  768 
operation  for  gall-stones  during,  149,  150 

on  gall-bladder  during,  149 
parametrial  hematoma  as  complication, 

260 
parametritis  as  complication,  257 
performance  of,  during  menstruation,  22 
Pfannenstiel's  incision,  769 
transverse  incisions  in,  768 
pain,  576 

peritonitis  as  result  of  gonorrheal  salpin- 
gitis, 201 
Pelvis  of  kidney,  inflammation,  273 
retroperitoneal  txunors,  423 
subperitoneal  tumors,  423 
varicose  veins  of,  120 
Percy's  treatment  of  carcinoma  of  cervix,  360, 

361,  790 
Pericystitis,  266 
Perineal  body,  491 
cysts,  301 

muscles,  functional  anatomy  of,  490,  491 
sheet,  Ewin,  directions  for  making,  843 
Perineoplasty,  Clark's,  633,  636 
Emmet's,  Graves'  modification,  625 


Perineoplasty,  Studdiford's,  638 
Perineum,  laceration  of,  490.    See  also  Lacera- 
tion of  perineum. 
plastic  surgery,  625 
tight,  operation  for  enlarging,  746 
Perisalpingitis,  tubercular,  216,  218 
Perithehoma  of  ovary,  411 
Peritoneal  adhesions,  153 

from  bacterial  peritonitis,  153 
from  chemical  injury,  154 
from  mechanical  injury,  154 
from  surface  necrosis,  155 
from  tuberculosis,  154 
tramnatic,  154 
cavity,  absorption  of  flmd  material  in,  152, 

153 
epithelium,  destruction  of,  152,  153 
bacterial  infection  as  cause,  153 
fluid,  transudation  and  resorption,  152 
Peritonemn,  inflammation  of,  pain  from,  578 
lymph-vessels  of,  151 
nerves  of,  151 
physiology  of,  150 
relation  of  genitaha  to,  150 
reparative  power  of  epithehum,  152 
resistance  of,  to  external  infection,  152 
tuberculosis  of,  221 
Peritonitis,  bacterial,  153 
gonorrheal,  153 
pelvic,  as  result  of  gonorrheal  salpingitis, 

201 
tubercular,  221 
diagnosis,  222 
dry  adhesive,  221 
nodular,  221 
prognosis,  223 
symptoms,  221 
treatment,  222 
with  ascites,  221 
Periurethral  abscess,  262 
PeriviteUine  space,  36 
Pessaries  for  anteflexion  of  cervix,  691 
of  uterus,  691 
in  amenorrhea  of  youth,  524 
in  anteflexion  of  uterus,  481 
in  oligomenorrhea  of  youth,  524 
in  procidentia  of  uterus,  478 
in  prolapse  of  uterus,  472,  473 
in  retroversion  of  uterus,  466 
Petit's  triangle,  798 
Pfannenstiel  incision,  769 
Pfannenstiel's  operation  in  dysmenorrhea,  521 
Phantom  pregnancy,  572 
Phlebectasis,  119 

operations  for,  828 
Phlebitis,  postoperative,  116,  117 


874 


INDEX 


Phlebitis,  postoperative,  pyogenic,  117 

treatment,  117 
Phlegmasia  alba  dolens,  116,  257  ' 
Physical  changes  during  menopause,  22 
Pigment  hypertrophy  and  functions  of  pelvic 

organs,  relation  between,  96 
Piles,  432.     See  also  Hemorrhoids. 
Pineal  gland,  internal  secretory  action  of,  90, 
91 
relation  of,  to  genitaha,  90,  91 
Pituitary  body.     See  Hypophysis. 
Pituitrin    in    gland    hypertrophy    of    endo- 
metrium, 251 
in   menorrhagia    due    to    uterine   fibroids, 
325 
of  youth,  525 
in  postpartum  hemorrhage,  79 
in  uterine  insufficiency,  548 
to  stimulate  uterine  contractions,  78 
value  of,  78,  79 

with  adrenalin  in  dysmenorrhea,  519 
Placenta,  influence  of,  on  breasts,  94 
on  mother  during  pregnancy,  92 
maternal,  47 

relation  of,  to  genitalia,  92 
Placental  extracts  in  amenorrhea,  65 
in  climacteric  disturbances,  65 
in  sterility,  65 
polyp,  372 

site,  chorio-epithehoma  maUgnum,  370 
Plastic  operations,  after-care,  845 
care  of  stitches,  846 
coaptation  of  woiind  edges,  845 
denudation  in,  844 
on  stump  of  Fallopian  tube,  563 
preparation  for,  842 
stitch  abscess  in,  treatment,  847 
suture  material,  844 
technic,  842 
technical  details,  843 
Plexus,  Auerbach's,  151 
Plugs,  dermoid,  402 

Pneumococcus  as  cause  of  secondary  infec- 
tions in  pelvis,  105 
Pneumonia,  ether,  103 

postoperative,  103 
Polypoid  gland  hypertrophy  of  endometrium, 

250,  574 
Polyposis,  rectal,  431 
Polyps,  cervical,  332 
bleeding  in,  333 
diagnosis,  334 
metrorrhagia  in,  576 
symptoms,  333 
treatment,  334 
.     mucous,  of  Fallopian  tubes,  421 


Polyps,  mucous,  of  vestibule,  293 
of  endometrium,  333,  334 
placental,  372 
rectal,  431 
Position,  knee-chest,  834 
of  uterus,  17  453 
Sims',  834 
Posthemorrhagic  blood-picture,  108 
Postmenstrual  involution  of  uterine  mucosa, 
28 
necrobiotic  endometritis,  248 
Postoperative  catharsis  in  abdominal  cases, 
840,  841 
in  plastic  cases,  846 
embohsm,  118 
hernia,  503 
diagnosis,  504 
Graves'  operation  for,  782 
transplantation  of  fascia  for,  782 

Bartlett's  method,  783 
treatment,  504 
hyperleukocytosis,  109 
infections  of  lungs,  103 
leukocjrtosis,  109 
myxedema,  82 

neuroses  after  hysterectomy  and  ovariec- 
tomy, 128 
parametrial  hematoma,  260 
parametritis,  257 
phlebitis,  116,  117 
pyogenic,  117 
treatment,  117 
pneinnonia,  103 
pyehtis,  275 
skin  eruptions,  97' 
thrombophlebitis,  116 
thrombosis,  116,  117 
treatment  of  abdominal  cases,  840 

of  bowels  of  abdominal  cases,  840,  841 

of  plastic  cases,  846 
of  plastic  cases,  845 
Postpartum  hemorrhage,  pituitrin  in,  79 
Pozzi's  operation  for  anteflexion  of  uterus, 
693 
in  dysmenorrhea,  521,  693 
Precocious  menstruation,  21 

in  infants,  18 
Pregnancy,  Abderhalden's  test  for,  110 
appendicitis  during,  146,  147 
atresia  of  folhcle  during,  41 
changes  in  hypophysis  in,  76 
complicating  ovarian  tumors,  414 
corpus  luteum  of,  macroscopic  appearance, 

59 
ectopic,  506.     See  also  Ectopic  pregnancy. 
effect  of  removal  of  hypophysis  on,  76 


INDEX 


875 


Pregnancy,  extra-uterine,  506.     See  also  Ec- 
topic ■pregnancy. 
following    ovarian    tissue   transplantation, 

62,  63,  565 
goiter  during,  SO,  81 
in  rudimentary  horn  of  uterus,  444 
influence  of  placenta  on  mother  diu:ing,  92 
interstitial,  506 

symptoms  and  course,  513 
myoma  of  uterus  and,  differentiation,  324 

relation,  322 
persistence  of  corpus  luteimi  and,  47 
phantom,  572 
tetany  in,  83,  84 

tubal,  506.     See  also  Ectopic  pregnancy. 
Premenstrual  congestion  of  uterine  mucosa, 

24 
Pressure,  pelvic,  pain  from,  578 
symptoms  of  ovarian  tumors,  412 

of  tumors   of  pelvic   connective  tissue, 
424 
Prevesical  space,  256 
Primordial  egg,  33 

folhcle,  33 
Private  house,  examination  of  patient  in,  834 
Procidentia  of  uterus,  457,  475 
after  hysterectomy,  477 
congenital,  476 
diagnosis,  477 
elongation  of  cervix  in,  477 
Goffe's  operation,  706 
Graves'  operation,  696 
interposition  operation,  479,  699 
Mayos'  operation,  709 
operations  for,  696 
pessaries  for,  478 
suspension  operation,  479 
symptoms,  478 
treatment,  478 
Watkins'  operation,  479,  699 
"VYertheim's  operation,  705 
Prolapse  of  anus,  431 
of  rectum,  431 
incomplete,  431 
Marchant's  operation,  817 
Moschowitz's  operation,  817,  818 
operations  for,  817 
suspension  operation,  817 
treatment,  432 

Tuttle's  modification  of  Ekehorn's  opera- 
tion, 817 
of  urethra,  294 

in  children,  295 
of  uterus,  457,  470 
diagnosis,  471 
Goffe's  operation,  706 


Prolapse  of  uterus,  Graves'  operation,  696 
interposition  operation,  479,  699 
Mayos''  operation,  709 
Olshausen's  operation,  474 
operations  for,  696 
symptoms,  472 
treatment,  472 
surgical,  473 
Watkins'  operation,  479,  699 
Wertheim's  operation,  705 
of  vaginal  wall,  457 
Protargol  in  cystitis,  270 

in    gonorrheal    inflammation    of    Skene's 
glands,  184 
urethritis,  183 

vulvovaginitis  in  children,  181 
Pruritus  of  vulva,  234 
etiology,  235 
radium  in,  531 
treatment,  235 
Pseudohermaphroditism,  71,  451 
Pseudomucin,  390 

Pseudomucinous  cystadenoma  of  ovary,  389 
origin,  397 
treatment,  391 
Pseudomyxoma  peritonei,  393 
Pseudovaginismus,  533 

treatment,  534 
Psychic  distiu-bances  during  menopause,  22 
states,    disturbed,    influence   of,    on   men- 
struation, 21, 123 
Psychonem-oses  after  ovariectomy  and  hys- 
terectomy, 128,  129 
genital,  124 

treatment,  127 
of  menopause,  129 
Ptosis,  abdominal,   158.      See  also  Enterop- 

tosis. 
Puberty,  acne  at,  96 
age  occurring,  18 
development  of  breasts  at,  18 
effect  of  chmate  on  occurrence  of,  18 
heart  at,  113 

ovariectomy  before,  in  women,  51,  52 
sexuality  of,  132,  133 
thyroid  at,  80 
Pubescent  uterus,  554 
Pubococcygeus  muscle,  490 
Puerperal  sepsis  as  cause  of  hemorrhage  in 
eye,  99 
of  sterihty,  557 
Pulley  stitch,  772 
PyeUtis,  273 

etiology,  273,  274 
postoperative,  275 
prognosis,  276 


876 


INDEX 


Pyelitis,  treatment,  276 
Pyelography,  171 
Pyelonephritis,  273,  275 
Pyometra,  247 
Pyosalpinx,  gonorrheal,  194 

profluens,  211,  569 

rupture  of,  204 

Race  degeneration  as  cause  of  sterility,  561 
Radium,  apphcation  of,  Graves'  technic,  792 
in  bleeding  from  uterine  fibroids,  325 
in  carcinoma  of  cervix,  348,  362 
details  of  treatment,  355 
Graves'  technic,  792 
selection  of  cases  for,  353 
of  rectum,  430 
of  vagina,  298 
in  endometritis,  531 
in  gland  hypertrophy  of  endometrium,  251, 

527 
in  interstitial  endometritis,  528 
in  kraurosis  of  vulva,  531 
in  menorrhagia  of  fibroids,  529 
of  pelvic  inflammation,  530 
of  yoimg,  528 
in  non-malignant  gjoiecologic  diseases,  525- 
533 
after-care,  532 
details  of  treatment,  531 
dosage,  531 

selection  of  cases,  526     ■ 
in  myoma,  325 
in  parametritis,  259 
in  pruritus  of  vulva,  236,  531 
in  sarcoma  of  uterus,  332 
in  uterine  insufficiency,  526,  549 
physical  properties,  348 
Rash,  ether,  97 

Receptaculum  seminis,  23,  554 
Recti  muscles,  diastasis  of,  500 
operation  for,  771-774 
ovarian  cyst  and,  differentiation,  416 
treatment,  501 
Rectocele,  144,  457,  471,  497 

closure  of    Douglas'    pouch    for.    Graves' 

operation,  643 
Graves'   modification   of  Emmet's   opera- 
tion, 625 
Rectovaginal  fistula,  operation  for,  652,  653 

septum,  adenomyomas  of,  305 
Rectum,  adenoma  of,  431 
atresia  of,  449 
carcinoma  of,  429.     See  also  Carcinoma  of 

rectum. 
effect  ,of  retroverted  uterus  on,  144 
endothelioma  of,  430 


Rectum,  epithelioma  of,  430 
inflammatory  stricture,  283 

treatment,  285 
operations  on,  817 
polyposis  of,  431 
polyps  of,  431 
prolapse    of,    431.     See    also    Prolapse    of 

rectum. 
relation  of  genitalia  to,  142,  144 
sarcoma  of,  430 
stricture  of,  inflammatory,  283 

treatment,  285 
tumors  of,  429 
Red  degeneration  of  uterine  myoma,  314,  316 
Regeneration  of  blood  after  hemorrhage,  108, 

109 
Regressive  changes  in  uterine  myoma,  316 
Reid's  genitomesenteric  fold,  173 
Relaxation  of  vaginal  waUs  as  cause  of  steril- 
ity, 558 
Resection  of  ovary.  764 
Respiration,  organs  of,  relation  of  genitalia 

to,  103 
Retrocession  of  uterus,  455,  461 
Retrodisplacement  of  uterus.     See  Retrover- 
sion of  uterus. 
Retroflexion  of  uterus,  455,  458 

relation  of  pelvic  inflammatory  disease 
to,  202 
Retrolocation  of  uterus,  456 
Retroperitoneal  appendix,  172 
dermoids,  425 
lipoma,  425 
sarcoma,  424,  425 
tumors,  423 
Retroposition  of  uterus,  456 
Retrorenal  fascia,  799 
Retroversion  of  uterus,  453,  458 

Alexander-Adams  operation,  689 
Alexander's  operation,  466,  688 
Baldy's  operation,  685 
Coffey's  operation,  468 
diagnosis,  465 
due  to  adhesions,  468 
diagnosis,  469 
symptoms,  469 
treatment,  469 
due  to  displacement  by  tumors,  470 
due  to  relaxation,  459 
symptoms,  463 
treatment,  466 
effect  of,  on  rectum,  144 
etiology,  458 
first  degree,  453 
Gilliam's  operation,  467,  680 
Kelly's  modification,  685 


INDEX 


877 


Retroversion  of  uterus,  GUliam's  operation, 
Mayos'  modification,  683 
Simpson's  modification,  681 
internal  Alexander  operation,  683 
Kelly's  operation,  685 
Mayos'  operation,  683 
Olshausen's  operation,  468 

Graves'  modification,  678 
operations  for,  678 
pathologic  conditions  due  to,  461 
pessaries  in,  466 
relation  of  pelvic  inflammatory  disease 

to,  202 
second  degree,  454 
Simpson's  operation,  681 
symptoms,  463 
third  degree,  454 
traumatic  adhesions  from,  462 
treatment,  466 
ventral  fixation,  467 

suspension,  467 
Webster-Baldy  operation,  468,  685 
Retroversion-flexion  of  uterus,  455 
Retzius,  space  of,  256 
Ripening  follicle,  33 
Rodent  ulcer  of  vulva,  229 
Rontgen  rays.     See  x-Rays. 
Round  ligament,  adenomyoma  of,  423 
fibromyoma  of,  424 
tumors  of,  422 
treatment,  423 
Rovsing's  operation  for  enteroptosis,  166 
Rudimentary  horn  of  uterus,  444 

uterus,  441 
Rupture  of  ovarian  cysts,  412 
of  pyosalpinx,  204 
of  tube  in  ectopic  pregnancy,  508 
pain  of,  577 
treatment,  513 
Russian  oil  in  enteroptosis,  164 

Sactosalpinx  serosa,  196 
Salivation,  menstrual,  100 

vicarious,  100 
Salpingectomy,  758 
Salpingitis,  catarrhal,  193 
chronic  interstitial,  199 
gonorrheal,  192 

acute,  appendicitis  and,  differentiation, 
206 
diagnosis,  205 

differential,  206 
diverticulitis  of  sigmoid  and,  differen- 
tiation, 207 
extra-uterine    pregnancy    and,    differ- 
entiation, 207 


Salpingitis,  gonorrheal,  acute,  secondary,  204, 
205 
treatment,  208 
symptoms,  203 
treatment,  208 

twisting  of  pedicle  of  ovarian  cyst  and, 
differentiation,  207 
as  cause  of  sterility,  556 

treatment,  562 
chronic    pelvic    inflammation  as  result, 
202,  209.    See  also  Pelvic  inflammation, 
chronic. 
pathology,  193 

pelvic  peritonitis  as  result,  201 
interstitial,  chronic,  199 
isthmica  nodosa,  201 
tubercular,  216 
progress,  218 
symptoms,  218 
treatment,  218 
Salpingo-oophorectomy,  757 
Salpingostomy,  stomatoplastic,  760 

Bell's  method,  762 
Sampson's   method   of   ureterovesical  trans- 
plantation, 812 
Sandalwood,  oil  of,  in  gonococcal  cystitis,  269 
Sarcoma  botryoides,  329 
cystic,  of  uterus,  330 
grape-mole,  of  uterus,  329 
of  endometrium,  329 
of  Fallopian  tubes,  421 
of  ovary,  410 

metastasis,  411 
of  pelvic  connective  tissue,  425 
of  rectum,  430 
of  uterus,  328 

adenocarcinoma  and,  differentiation,  331 
bleeding  from  uterus  in,  331 
cystic,  330 
diagnosis,  330 
grape-mole,  329 
histology,  329 
metastasis,  331 
treatment,  332 
of  vagina,  296 

in  children,  297 
of  vulva,  292 
retroperitoneal,  424,  425 
Sarcomatous  degeneration  of  uterine  fibroids, 

317,  329,  331 
Scarlet  ointment  in  varicose  ulcer,  830 
Schauta's  operation  for  carcinoma  of  cervix, 

744-750 
Schroder's  operation  for  extirpation  of  endo- 
cervix,  604 
for  sterility,  564,  604 


878 


INDEX 


Schubert's  operation  for  absence  of  vagina, 

670 
Schultz's  theory  of  etiology  of  dysmenorrhea, 

516 
Seborrhea  of  vulva,  225 

Secretion,  abnormal,  symptoms  due  to,  568 
internal,  effect  of  nervous  system  upon,  44, 
45 
glands  of,  dysfunction  of,  45 
hjHperfunctional  changes  in,  45 
hypofunctional  changes  in,  45 
relationship  of  g5Tiecology  to,  44 
of  ovary  to,  46 
of  uterus,  91 
ovarian,  46 

absence  of,  ovarian  extract  in,  65 
loss  of,  as  cause  of  changes  during  meno- 
pause, 23 
Semen,  escape  of,  from  vagina,  as  cause  of 

sterility,  555 
Senile  vaginitis,  544 

Sense,  organs  of,  relation  of  genitalia  to,  98 
Sepsis,  puerperal,  as  cause  of  hemorrhage  of 
eye,  99 
of  sterility,  557 
Septum  formation  of  vagina,  444 
partial,  of  uterine  cavity,  443 
rectovaginal  adenomyomas  of,  305 
Serodiagnosis  of  pregnancy  and  cancer,  110 
Serous  cystadenoma  of  ovary,  393 

origin,  396 
Serum,  antigonococcic,  215 

blood,  in  menorrhagia  of  youth,  525 
treatment  of  gonorrhea,  214 
of  hemophilia,  107 
Sex,  determination  of,  68-72 

impulse,  relation  of  genitalia  to,  129 
Sexual  anesthesia,  134,  136,  138 
deviations,  134 
dyspareunia,  138 
masturbation,  134 
herpes,  95 
impulse  during  menstruation,  21 

just  before  menopause,  23 
sensibility,  local,  lack  of,  139 
Sexuality,  infantile,  130 

masturbation  in,  132,  133 
onanism  in,  131,  132 
second  period  of,  133,  134 
thumb-sucking  as  manifestation,  131 
of  puberty,  132,  133 
Shaw's  principles  of  technic  in  fascia  trans- 
plantation, 786 
Shock,  nervous,  influence  of,  on  menstrua- 
tion, 123 
Side,  pain  in,  579 


Sigmoid,   diverticulitis  of,   acute  gonorrheal 
salpingitis  and,  differentiation,  207 

relation  of  genitalia  to,  144 
Silver  nitrate  in  anal  fissure,  283 
in  chronic  urethritis,  262 
in  cystitis,  270 
in  pyehtis,  277 
Simpson's     operation     for     retroversion     of 

uterus,  681 
Sims'  operation  for  vesicovaginal  fistula,  653 

position,  834 
Sinus,  urogenital,  441 
Sippel's  theory  of  cause  of  ectopic  pregnancy, 

506 
Skene's  glands,  gonorrheal  inflammation  of, 

183 
Skin,  condition  of,  during  menstruation,  21 

edema  of,  associated  with  menstruation  and 
chmacteric,  96 

eruptions,  postoperative,  97 

lesion  from  vicarious  menstruation,  96 
of  vulva,  225 

menstrual  changes  in,  95 

relation  of  genitaha  to,  94 
Shding  hernia,  432 
Social  conditions,  effect  of,  on  occurrence  of 

menstruation,  19 
Sodium  citrate  in  dysmenorrhea,  519 
Somatic  cells,  407 
Space  of  Retzius,  256 

perivitelline,  36 

prevesical,  256 

uterovesical,  202 
Spasm  of  vagina,  533 

Spermatozoon  and  ovary,  place  of  union,  24 
Spinelli's  operation  for  inversion  of  uterus,  711 
Splanchnoptosis,  158.     See  also  Enteroptosis, 
Sponge  in  abdominal  cavity,  837 
Spongy  layer  of  uterine  mucosa,  26 
Spot,  genital,  100,  517 
Squamous-cell  carcinoma  of  cervix,  335 
Stasis,  intestinal,  158,  163 
Status  thymicus,  91 
Steam  in  uterine  insufficiency,  548 
Stenosis,  callous,  of  cervix,  555 

of  vagina,  536 
treatment,  540 
Sterility,  549 

absolute,  549 

acquired,  549 
causes  of,  556 

adiposity  as  cause,  560 

artificial  impregnation  in,  566 

carcinoma  as  cause,  558 

consanguinity  as  cause,  561 

constitutional  diseases  as  cause,  560 


INDEX 


879 


Sterility,  diseases  of  hypophysis  as  cause,  560 

effluvium  seminis  as  cause,  555 

endocervicitis  as  cause,  557 
treatment,  564 

endometritis  as  cause,  557 

escape  of  semen  from  vagina  as  cause,  555 

etiology,  550 

fetalism  as  cause,  550 

genital  tuberculosis  as  cause,  558 

gonorrheal  salpingitis  as  cause,  556 
treatment,  562 

in  retroversion  of  uterus,  464 

infantilism  as  cause,  550 
ovaries  in,  551 
tubes  in,  553 
uterus  in,  553 

lactation,  560 

malposition  of  uterus  as  cause,  558 
treatment,  561 

myoma  of  uterus  as  cause,  559 

obesity  as  cause,  560 

ovarian  extract  in,  65,  566 

implantation  and  transplantation  in,   62, 
565 

placental  extracts  in,  65 

preventive  measures  as  cause,  560 

primary,  549 

puerperal  sepsis  as  cause,  557 

race  degeneration  as  cause,  561 

relaxation  of  vaginal  walls  as  cause,  558 

Schroder's  operation  for,  564,  604 

secondary,  549 

treatment,  561 

tumors  as  cause,  558 

vaginismus  as  cause,  561 

x-ray  as  cause,  559 
Sterilization,  tubal,  Taussig's  operation,  762 
Stigma,  ovarian,  37 
Stitch.     See  Suture. 
Stomach,  disturbances  of,  and  menstruation, 

relationship,  100,  101 
Stone.     See  Calculus. 
Strain,  foot,  156 

Strawberry  mottling  of  gall-bladder,  150 
Stricture,  inflammatory,  of  rectum,  283 
treatment,  285 

of  urethra,  262 

as  result  of  gonorrheal  urethritis,  183 
Stromatogenous  tumors  of  ovary,  407 
Struma  ovarii,  404 

Studdiford's  method  of  combined  amputation 
of  cervix  and  anterior  colpoplasty,  620 

perineoplasty,  638 
Subconsciousness,  125 
Subperitoneal  tumors,  423 
Suicide  during  menstruation,  123 


Superior  lumbar  trigonum,  798 
Suppurating  kidney,  273 
Suprapubic  cystotomy,  815 

Kelly's  method,  815 
Suprarenal  system,  84 
anatomy,  84,  85 
hyperfunction  of,  88 
hypertrophy  of,  after  ovariectomy,  89 
internal  secretory  function  of,  85 
relation  of,  to  genitalia,  85,  87 
Supravaginal  hysterectomy,  713 
vaginal  drainage  after,  723 
Suspension  of  kidney,  796 
Kelly's  technic,  800 
of  uterus  for  anteflexion,  482 

Graves'     modification     of     Olshausen's 

operation,  678 
in  procidentia,  479 
operation  for  rectal  prolapse,  817 
Suture  abscess  in  plastic  operations,    treat- 
ment, 847 
Brodel's,  803 

care  of,  in  plastic  operations,  846 
material  in  abdominal  operations,  838 

in  plastic  operations,  844 
of  abdominal  wound,  839 
pulley,  772 

wandering,  as  cause  of  vesical  calculus,  428 
Symptomless  cholelithiasis,  148 
Symptoms,  568 

due  to  abnormal  secretions,  568 
essential,  568 
Syncytioma  mahgnum,  370 
Syncytium,  372 
Syphilis  of  bladder,  272 

of  vulva,  225 
Syphilitic  cystitis,  272 

Tampons,  vaginal,  in  prolapse  of  uterus,  472 
Taussig's  operation  for  carcinoma  of  vulva, 
291,  584 
•  for  tubal  sterilization,  762 
Technic,  831 

Temperament,  change  in,  after  fifty,  23 
Temperature,  elevation  of,  in  carcinoma  of 

cervix,  343 
Teratoma  of  ovary,  404 
parthenogenesis,  405 
of  vulva,  292 
Test,  Abderhalden's,  for  pregnancy  and  can- 
cer, 110 
in  differential  diagnosis  of  uterine  myoma 
and  pregnancy,  324 
complement-fixation,  in  diagnosis  of  gonor- 
rheal salpingitis,  205 
Tetany  in  pregnancy,  83,  84 


880 


INDEX 


Tetany,  parathyroid  extract  in,  83,  84 
Theca  externa,  34,  49 
folliculi,  34 

tunica  externa  of,  34 
interna  of,  34,  36 
interna,  34,  36 
Theca-luetin  cells,  387 
function  of,  50 
cysts,  3S7 
Thread-worms,     vulvovaginitis    in    children 

from,  238 
Thrombophlebitis,  postoperative,  116 
Thrombosis,  postoperative,  116,  117 
Thrombotic  degeneration  of  uterine  myoma, 
314 
pile,  433 
Thumb-sucking  manifestation  of  sexual  im- 
pulse, 131 
Thymus,  relation  of,  to  genitalia,  91 
Thjrreaplasia,  82 

ThjToid  and  myoma  of  uterus,  relation  be- 
tween, 81 
at  puberty,  80 

enlargement  of,  during  menstruation,  20 
extract    and   pituitrin   in   menorrhagia   of 

youth,  525 
influence  of  menopause  on,  81 
relation  of  ovary  to,  80 
to  genitalia,  79,  80 
Tight  perineum,  operation  for  enlarging,  646 
Torsion  of  ovarian  cysts,  413 

acute  gonorrheal  salpingitis  and,  differ- 
entiation, 207 
tumors,  413 
of  uterus,  457 
Tracheloplasty,  593 

Emnaet's  operation,  593 
Transfusion,  blood,  in  hemophilia,  107 

in  menorrhagia  of  youth,  525 
Transplantation  of  fascia  for  postoperative 
hernia,  782 
Bartlett's  method,  783 
'    Shaw's  principles  of  technic,  786 
of  ovarian  tissue,  60,  765 

after  hysterectomy,  63,  763 

in   functional   amenorrheas   of   young 

women,  64 
in  horn  of  uterus,  61,  62 
in  sterihty,  62,  565 
ureterovesical,  812 

Sampson's  method,  812 

Kronig's  modification,  813 
Transudation   and   resorption   of   peritoneal 

fluid,  152 
Transverse    incisions    in    pelvic    operations, 
768 


Traumatic    adhesions    from    retroversion    of 

uterus,  462 
peritoneal  adhesions,  154 
theory  of  etiology  of  cervical  cancer,  339- 

342 
Treves'  bloodless  fold,  172 
Triangle,  Petit's,  798 
Trichloracetic  acid  in  dysmenorrhea,  520 
Trichomonas  vaginaUs,  238 
Trophoblast    and    chorio-epithelioma    malig- 

num,  biologic  resemblance,  375 
function  of,  375 
Tubal  abortion,  508 

treatment,  514 
menstruation,  30 
mole,  508,  511 

pregnancy,    506.     See    also    Ectopic    preg- 
nancy. 
rupture  in  ectopic  pregnancy,  508 
treatment,  513 
Tubercular  cystitis,  271 

treatment,  269 
endometritis,  219 
endosalpingitis,  216,  217 
metritis,  251 
oophoritis,  253 
perisalpingitis,  216,  218 
peritonitis,  221 

diagnosis,  222 

dry  adhesive,  221 

nodular,  221 

prognosis,  223 

symptoms,  221 

treatment,  222 

with  ascites,  221 
salpingitis,  216 

progress,  218 

symptoms,  218 

treatment,  218 
Tuberculosis,  amenorrhea  and,  relationship, 

572 
genital,  215 

as  cause  of  sterility,  558 
of  bladder,  271 

diagnosis,  271 

treatment,  271 
of  cervix,  220 
of  endometrium,  219 
of  Fallopian  tubes,  216 
of  lungs,  influence  of  menstruation  on,  104 
of  metrium,  219,  251 
of  ovary,  220,  253 
of  peritoneum,  221 
of  uterus,  219,  251 
of  vagina,  220 
of  vulva,  220 


INDEX 


881 


Tubo-ovarian  abscess,  196,  253 

cysts,  198 
Tubo-ovaritis,  chronic,  200 

gonorrheal,  195 
Tumors,  abdominal,  ^atiligo  associated  with, 
97 
as  cause  of  sterility,  558 
Krukenberg's,  407 
of  bladder,  426 
s3'mptoms,  428 
treatment,  428 
of  clitoris,  295 
of  Fallopian  tubes,  420 
of  kidney,   ovarian  tumors   and,   differen- 
tiation, 415 
of  ovary,  381.     See  also  Ovary,  tumors  of. 
of  parovarium,  419 
of  pehac  connective  tissue,  423 
symptoms,  424 
treatment,  426 
of  rectum,  429 
of  round  ligament,  422 

treatment,  423 
of  uterus,  307 
of  vagina,  296 
of  \Tilva,  287 
retroperitoneal,  423 
subperitoneal,  423 
Tunica  externa  of  theca  folliculi,  34 

interna  of  theca  folliculi,  34,  36 
Tuttle's  modification  of  Ekehorn's  operation 

for  rectal  prolapse,  817 
Typhoid  fever  and  genitaha,  relation  between, 
157 

Ulcer  of  bladder,  265 
rodent,  of  vulva,  229 
varicose,  Crede's  ointment  in,  830 
operations  for,  830 
scarlet  ointment  in,  830 
Ulceration  of  cervix,  336,  485,  486 

of  A^ilva,  229 
Ulcus  moUe  of  AOilva,  224 
Umbilical  hernia,  502 

Graser's  operation  for,  781 
Graves'  operation  for,  775 
Mayos'  operation  for,  781 
Upper  pedicle,  585,  586 
Uremia,  chronic,  from  pressure  of  tumor  of 

pelvic  connective  tissue,  424 
Ureter,  implantation  of^  in  bladder,  812 
in  colon,  814 
operations  on,  810 
proximal  end,  hgation  of,  813 
relation  of  genitaha  to,  142,  143 
symptoms  of  ovarian  tumors,  412 
56 


Ureteral  anastomosis,  810,  811,  812 

fistula,  formation  of,  814 
Ureterocystanastomosis,  812 
Ureterocystostomy,  810 
Uretero-ureterostomy,  810 
Ureterovesical  transplantation,  812 
Sampson's  method,  812 

Ivronig's  modification,  813 
Urethra,  atrophy  of,  545 
defects  of,  445 
l^rolapse  of,  294 

in  children,  295 
stricture  of,  262 

as  result  of  gonorrheal  urethritis,  183 
Urethral  canal,  diverticula,  301 
caruncle,  293 

mucous  membrane,  ectropion  of,  545 
treatment,  547 
Urethritis,  261 
acute,  261 
chronic,  261 

treatment,  262 
gonorrheal,  181 

cystitis  and,  differentiation,  266 
stricture  of  urethra  as  result,  183 
symptoms,  182 
treatment,  183 
Urethrocele,  488 
diagnosis,  489 
Urethrovaginal  fistula,  498 
Urine,    incontinence    of,    functional,    Kelly's 
operation,    combined   with   Graves' 
anterior  colpoplasty,  615 
operation  for,  614 
leakage  of,  in  vesicovaginal  fistula,  499 
Urogenital  sinus,  441 
Urotropin  in  cystitis,  269 
Uterine  canal,  radiimi  apphcation  in,  technic, 
795 
cavity,  partial  septum,  443 
cohc,  577 

contractions,  pituitrin  to  stimulate,  78 
extracts,    influence    of,    on    time    coagula- 

bihty  of  blood,  58 
hemorrhage.     See  Metrorrhagia. 
insufficiency,  547 
diagnosis,  548 
radium  in,  526 
symptoms,  548 
treatment,  548 
mucosa,  compact  layer,  26 
cyclic  changes  in,  24 
glycogen  production  from,  30 
menstrual  exfoUation,  522 

flow  and,  28 
postmenstrual  involution  of,  28 


882 


INDEX 


Uterine  mucosa,  premenstrual  congestion  of, 
24 

spongy  layer,  26 
Uterovesical  fistula,  operation  for,  659   • 

space,  202 
Uterus,  absence  of,  441 
adenocarcinoma  of,  362 

sarcoma  and,  differentiation,  331 
adenomyoma  of,  327 
adenomyositis  of,  327 
adenosarcoma  of,  330 

amputation  of,  713.    See  also  Hysterectomy. 
angiosarcoma  of,  330 
anteflexion  of,  455,  480.     See     also     A?ite- 

flexion  of  uterus. 
anteposition  of,  456 
anteversion  of,  455 
atresia  of,  444 
atrophy  of,  541 
bicornis  unicolUs,  442 
bicornuate,  442 

double,  with  double  vagina,  441 
biforis,  443 
carcinoma  of,  362.     See  also  Carcinoma  of 

uterus. 
condition  of,  during  lactation,  543 

during  menstruation,  20 
congenital  defects,  441 
curetage  of,  592 
cystic  sarcoma,  330 
defects  of,  congenital,  441 
descent  of,  457 
didelphys,  441 
double,  442,  443,  444 
duplex  bicornis,  442 

cum  vagina  dupUci,  442 

separatus,  441 
dwarf,  554 
elongation  of,  458 
embryologic  development,  436 
examination  of,  833 

fibroids  of,  307.     See  also  Myoma  of  uterus. 
fibromyoma  of,  307.     See  also  Myoma  of 

uterus. 
flexion  of,  lateral,  455 
hemorrhage  from.     See  Metrorrhagia. 
hyperanteflexion  of,  455 
hjTDertrophic  changes  in,  before  and  after 

birth,  17 
in  infantilism  as  cause  of  steriUty,  553 
infantile,  553 
infantiUsm  of,  480 
infections  of,  251 
inflammation  of,  251 

gonorrheal,  251 

infectious,  251 


Uterus,  inflammation  of,  tubercular,  251 
internal  secretion  of,  91 
inversion  of,  458,  482.     See  also  Inversion 

of  uterus. 
leiomyoma  of,   307.     See  also  Myoma  of 

uterus. 
lymphosarcoma  of,  330 
malpositions  of,  453 

as  cause  of  sterility,  558 
treatment,  561 

backache  in,  579 

dysmenorrhea  and,  relation,  517 

operations  for,  678 
melanosarcoma  of,  330 
myoma  of,  307.    See  also  Myoma  of  uterus. 
myosarcoma  of,  329 
physiology  of,  17 
position  of,  17,  453 
procidentia  of,  457,  475.     See  also  Proci- 

deritia  of  uterus. 
prolapse  of,  457,  470.     See  also  Prolapse  of 

uterus. 
pubescent,  554 

removal  of,  713.     See  also  Hysterectomy. 
retrocession  of,  455,  461 
retrodisplacement  of.     See  Retroversion  of 

uterus. 
retroflexion  of,  455,  458 

relation  of  pelvic  inflammatory  disease 
to,  202 
retrolocation  of,  456 
retroposition  of,  456 

retroversion  of,  453,  458.     See  also  Retro- 
version of  uterus. 
retroversion-flexion,  455 
rudimentary,  441 

horn,  444 
sarcoma  of,  328.   See  also  Sarcoma  of  uterus. 
septus  duplex,  443 

size  and  weight  of,  influence  of  child-bear- 
ing on,  17 
subseptus  uniforis,  443 
suspension  of,  for  anteflexion,  482 

Graves'  modification  of  Olshausen's  op- 
eration, 678 

in  procidentia,  479 
torsion  of,  457 
tuberculosis  of,  219,  251 
tumors  of,  307 
unicornis,  443 
version  of,  lateral,  ^55 
version-flexion  of,  455 

Vaccine  treatment  of  gonorrhea,  214 

of  gonorrheal  vulvovaginitis  in  children, 
181 


INDEX 


883 


Vaccine  treatment  of  pyelitis,  277 

of  vulvovaginitis  in  cliildren,  215 
Vaccines,  antigonococcic,  215 
Vagina,  absence  of,  444,  536 

Baldwin's  operation  for,  670 

Graves'  operation  for,  667 

operations  for,  667 

ovaries  and,  55 

Schubert's  operation  for,  670 

treatment,  540 
adenomyoma  of,  305 

artificial,    Baldwin's    method    of    making, 
670 

Graves'  method  of  making,  667 

method  of  making,  444,  667 

Schubert's  method  of  making,  670 
atrophy  of,  542 
carcinoma  of,  297 

diagnosis,  297 

prognosis,  298 

treatment,  298 

chorio-epitheUoma  of,  299 
cysts  of,  299 

diagnosis,  300 

etiology,  300 

treatment,  301 
defects  of,  developmental,  444 
digital  examination  by,  832 
Distoma  haematobium  in,  238 
embryologic  development,  436 
escape  of  semen  from,  as  cause  of  sterility, 

555 
expulsion  of  gas  from,  240 
fibromyoma  of,  304 
fungus  of,  238 
inflammation  of,  236 
myoma  of,  304 
operations  on,  608 
parasites  of,  238 
plastic  surgery  on,  608 
sarcoma  of,  296 

in  children,  297 
septum  formation,  444 
spasm  of,  533 
stenosis  of,  536 

treatment,  540 
tuberculosis  of,  220 
tumors  of,  296 
varicose  veins  of,  119 
Vaginal  anus,  451 
colpotomy,  675 
anterior,  676 
posterior,  677 
cystostomy,  815 

Dudley's  method,  815 
Kelly's  method,  816 


Vaginal  drainage  after  supravaginal  hyster- 
ectomy, 723 
hysterectomy,  728 

for  carcinoma  of  cervix,  744-750 
myomectomy,  756 
tampons  in  prolapse  of  uterus,  472 
wall,  prolapse,  457 

relaxation,  as  cause  of  sterility,  558 
Vaginismus,  533 

as  cause  of  sterility,  561 
false,  533 
treatment,  534 
Vaginitis,  236 

acute  septic,  after  acute  infectious  diseases, 

157 
emphysematosa,  239 
etiology,  237 
prognosis,  239 
senile,  544 
symptoms,  238 
treatment,  238 
Vaporization  in  uterine  insufficiency,  548 
Varices,  119 

operations  for,  828 
Varicocele  of  vulva,  293 
Varicose  ulcer,  Credo's  ointment  in,  830 
operations  for,  830 
scarlet  ointment  in,  830 
veins,  119 

Mayos'  operation  for,  829 
of  vulva,  293 
operations  for,  828 
Vasomotor  disturbances   after  ovariectomy, 
55,  128 
during  menstruation,  21 
of  menopause,  114,  129 
sensitiveness,  113 
symptoms  in  uterine  fibroids,  115 
Veins,  varicose,  119 

Mayos'  operation  for,  829 
of  vulva,  293 
operations  for,  728 
Ventral  fixation  in  retroversion  of  uterus,  467 

suspension  in  retroversion  of  uterus,  467 
Vermiform  appendix,  relation  of  genitaha  to, 
145 
retroperitoneal,  172 
Version  of  uterus,  lateral,  455 
Version-flexion  of  uterus,  455 
Vesical.     See  Bladder. 
Vesicocervicovaginal  fistula,  498 

operation  for,  659 
Vesico-uterine  fistula,  498 

operation  for,  659 
Vesicovaginal  fistula,  498 

Braquehaye's  operation,  657 


INDEX 


Vesicovaginal  fistula,  Braquehaye's  operation, 
Albarran's  modification,  657,  659 

operations  for,  653 

Sims'  operation,  653 
Vestibular  anus,  451 
Vestibule,  caruncle  of,  293 
mucous  polyp  of,  293 
papillary  angioma  of,  293 
Vicarious  dysmenorrhea,  113 
menstruation,  21 

skin  lesion  from,  96 
salivation,  100 
Visceroptosis,  158.     See  also  Enteropiosis. 
Vitiligo  associated  with  abdominal  tumors,  97 
Vocal  cords  during  menstruation,  21,  104 
Voice  after  ovariectomy,  52 

during  menstruation,  21,  104 
Vulva,  adenoma  hidradenoides,  287 
Bilharzia  hsematobia,  238 
carcinoma  of,  287 

Bassett's  operation,  584,  585 

diagnosis,  289 

operative  treatment,  584 

Taussig's  operation  for,  291,  584 

treatment,  290 
chancre  of,  soft,  224 
condyloma  acuminata  of,  227 

treatment,  228 
cysts  of,  sebaceous,  225 
Distoma  haematobium  in,  238 
echinococcus  cyst,  292 
eczema  intertrigo,  225 
elephantiasis  of,  230 
enchondroma  of,  292 
epithelioma  of,  289 
esthiomene  of,  229 

treatment,  230 
fatty  tumors,  287 
fibroma  of,  286 

molluscum  pendulum,  287 

treatment,  287 
fibromyoma  of,  286 
furunculosis  of,  225 
hydrocele  muliebris,  292 
inflammations  of,  224 
kraurosis  of,  232 

radium  in,  531 

treatment,  233 
leukoplakia  of,  234 
lipoma  of,  287 
lupus  of,  220 
myxoma  of,  292  _ 
neuroma  of,  292 
operations  on,  582 
osteoma  of,  292 
Paget's  disease  of,  234 


Vulva,  papillary  excrescences,  227 

pruritus  of,  234 
etiology,  235 
radium  in,  531 
treatment,  235 

renioval  of,  indications,  582 

rodent  ulcer,  229 

sarcoma  of,  292 

sebaceous  cysts,  225 

seborrhea  of,  225 

skin  lesions,  225 

soft  chancre,  224 

syphilis  of,  225 

teratoma  of,  292 

tuberculosis  of,  220 

tumors  of,  286 

ulceration  of,  229 

ulcus  molle,  224 

varicocele  of,  293 

varicose  veins  of,  119,  293 

warty  excrescences,  227 
Vulvectomy,  582 
Vulvitis,  224 

gonorrheal,  179 
Vulvovaginitis,  gonorrheal,  in  children,  179 
treatment,  180 

in  children  from  thread-worms,  238 
vaccine  treatment,  215 


Walthaed's     method     of     examination     in 

vaginismus,  534 
Wandering  stitch  as  cause  of  vesical  calculus, 

428 
Warren's    apron   incision   in  fistula  in  ano, 
825 
operation  for  complete  laceration  of  peri- 
neum, 652 
Warty  excrescences  of  vulva,  227 
Watkins'  operation  for  prolapse  and  proci- 
dentia of  uterus,  479,  699 
Wave  theory  of  menstruation,  120 
Webster-Baldy  operation  for  retroversion  of 

uterus,  468,  685 
Wertheim's  operation  for  carcinoma  of  cervix, 
731-744 
of  uterus,  731-744 
for  prolapse  and  procidentia  of  uterus, 
705 
Whitehead's  operation  for  carcinoma  of  rec- 
tum, 430 
for  hemorrhoids,  819 
Wilms'  cecum  mobile,  159,  169 

operation  for  enteroptosis,  165 
Wolffian  bodies,  436 
retrogression,  438 


INDEX 


885 


Wolffian  ducts,  436,  441 

retrogression,  438 
Wounds,  postoperative  hernia,  503 

Z-RAT  as  cause  of  sterility,  559 

in  bleeding  from  uterine  fibroids,  325 

in  carcinoma  of  cervix,  348 

in  gland  hypertrophy  of  endometrium,  251 


X-ray  in  menorrhagia  of  youth,  533 
in  pruritus  of  vulva,  236 
in  sarcoma  of  uterus,  332 
in  uterine  insufficiency,  549 

Zinc  chlorid  in  carcinoma  of  cervix,  362 

Zona  pellucida,  36 

Zuckerkandl,  accessory  organs  of,  85 


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expiration  of  a  definite  period  after  the  date  of  borrowing, 
provided  by  the  rules  of  the  Library  or  by  special  ar- 


rangement with  the  Librarian  in  charge. 


CZ8(t  140)  Ml  00 


